Non-exposure LECS (CLEAN-NET) for gastric cancer: long-term outcomes of a function-preserving strategy with selective nodal assessment - Surgical Endoscopy

Background Non-exposure laparoscopic and endoscopic cooperative surgery (LECS), known as CLEAN-NET (combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique), was developed for gastric submucosal tumors; however, its oncologic validity for gastric cancer remains unclear. We evaluated long-term oncologic outcomes of CLEAN-NET in patients with clinically diagnosed cT1N0 gastric cancer during the early developmental phase of this technique. Methods We retrospectively analyzed 19 consecutive patients who underwent CLEAN-NET between December 2008 and June 2010. Treatment selection was based on preoperative clinical staging available at that time. Limited regional lymph node assessment was performed in selected cases, and pathological findings were classified according to the eCura system. Recurrence of the gastric cancer treated by CLEAN-NET, metachronous gastric cancer, overall survival, and causes of death were evaluated. Results The median follow-up period was 6.2 years, with follow-up extending up to 16.8 years. Although treatment selection was based on preoperative cT1N0 assessment, 14 patients (73.7%) were subsequently classified as eCuraC-2 because of postoperative pathological risk factors. Limited regional lymph node dissection was performed in 15 patients, and pathological lymph node metastasis was identified in 1 patient. Additional surgery was performed in 3 patients. No recurrence of the gastric cancer treated by CLEAN-NET was observed. Metachronous gastric cancer developed in the preserved stomach in 2 patients, including 1 death from metachronous gastric cancer. During follow-up, 3 patients died: 1 from lung cancer, 1 from metachronous gastric cancer, and 1 from pneumonia. Conclusion This historical cohort provides rare ultra-long-term observational data after CLEAN-NET for gastric cancer. Although no recurrence of the gastric cancer treated by CLEAN-NET was observed, the findings do not establish CLEAN-NET as an alternative to guideline-recommended gastrectomy. Rather, they may inform future studies of function-preserving, non-exposure local resection combined with validated nodal navigation strategies. Graphical Abstract

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Early prediction of anastomotic leakage within 24 h after minimally invasive colorectal cancer surgery using postoperative inflammatory markers: development and temporal validation of a machine learning model - Surgical Endoscopy

Purpose Early identification of anastomotic leakage (AL) is critical for safe discharge within enhanced recovery pathways. This study developed and prospectively validated a machine learning (ML) model to predict AL using 24-h postoperative inflammatory biomarkers. Methods We analyzed 1,961 patients undergoing elective minimally invasive colorectal resection (2012–2025). Five ML architectures were developed using a 70/15/15 split. The Regularized Logistic Regression (RLB) model was selected and locked with a pre-specified threshold (0.1258). Global variable importance and directionality were assessed via SHAP analysis. Prospective temporal validation was performed on 250 consecutive patients (February 2024 – December 2025). Results AL incidence was 9.8% in the development cohort. The RLB model achieved high discrimination (AUCPR 0.859; AUC-ROC 0.819). Postoperative C-reactive protein (CRP) and the Systemic Inflammation Response Index (SIRI) at 24 h were the strongest predictors. During temporal validation, despite a 70% relative reduction in AL incidence (2.8%), the model maintained a robust negative predictive value (NPV) of 97.9% (95% CI 95.1–99.1% and an AUC of 0.73 (95% CI 0.54–0.92). Calibration was near-optimal (slope 0.987, intercept 0.505). Decision curve analysis demonstrated superior net clinical benefit across risk thresholds of 5–20%. Conclusions ML-based integration of early inflammatory biomarkers provides a reliable "safety filter" for postoperative surveillance. The high NPV supports objective decision-making for early discharge, even in changing clinical environments with decreasing complication rates.

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Robotic versus open pancreatoduodenectomy after completion of the learning curve: a propensity score–matched and CUSUM analyses of perioperative outcomes - Surgical Endoscopy

Background Robotic pancreatoduodenectomy (R-PD) has emerged as a minimally invasive alternative to open pancreatoduodenectomy (O-PD), although its role remains debated due to technical complexity and heterogeneous outcomes. This study compared perioperative outcomes between R-PD and O-PD in a high-volume center while minimizing the impact of the learning curve, and additionally evaluated the progressive improvement in surgical outcomes between the early and late phases of the robotic experience through comparative analyses and CUSUM assessment. Methods A single-center propensity score–matched retrospective cohort study was conducted using a prospectively maintained database of patients undergoing PD between January 2020 and December 2025. The most recent 50 consecutive R-PDs (late group, LR-PD) were compared with O-PD after 2:1 matching (matched open group, MO-PD) to balance baseline characteristics. Perioperative, postoperative, and pathological outcomes were compared, and multivariable analyses were performed to identify independent predictors of key outcomes. A subgroup analysis comparing the first 50 R-PDs (early group, ER-PD) with the subsequent 50 cases (LR-PD) was also performed, along with CUSUM analyses of outcomes showing differences between the two phases of the robotic experience. Results After matching, 100 MO-PD patients were compared with 50 LR-PD patients. LR-PD was associated with significantly lower estimated blood loss (EBL) (200 vs 300 mL; p = 0.0012) and shorter length of hospital stay (LOS) (12 vs 14 days; p = 0.038), but longer operative time (OT) (582 vs 362 minutes; p < 0.001). Rates of major complications (Clavien–Dindo ≥ III) and pancreas-specific complications were comparable between groups. A significantly lower incidence of postoperative lymphatic fistula was observed in the LR-PD (4 vs 15%; p = 0.045). At multivariable analysis, the LR-PD was independently associated with lower EBL (β − 116.80; p = 0.023), shorter LOS (β − 1.48; p = 0.041), and a reduced risk of postoperative lymphatic fistula (OR 0.30; p = 0.047), while remaining an independent predictor of longer OT (β 99.75; p < 0.001). Within the R-PD, OT was significantly shorter in the LR-PD compared with the ER-PD (582 vs 705 minutes; p < 0.001). CUSUM analyses identified inflection points at cases 51, 55, and 53 for OT, major complications, and clinically relevant PPH, respectively. Conclusions In a high-volume setting after the learning curve, R-PD is a potentially safe and feasible alternative to O-PD, offering reduced EBL, shorter LOS, and lower incidence of lymphatic fistula, despite longer OT. Further prospective studies are warranted to confirm these findings. Graphical abstract

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Prognostic Relevance of Surgical Margins According to KRAS and BRAF Status in Colorectal Liver Metastases: BRAF-KRAS LiverMet Collaborative Group - Annals of Surgical Oncology

Background Hepatic resection combined with systemic therapy represents the standard of care for colorectal liver metastases (CRLMs). Although parenchyma-sparing surgery prioritizes R0 resection and preserves liver function, the clinical relevance of minimal margins remains debated. At the same time, tumor biology, particularly KRAS and BRAF mutations, has emerged as a key determinant of outcomes. This study investigated whether mutational status modifies the impact of resection margin type on survival and recurrence. Methods This international multicenter study included patients undergoing curative-intent liver resection for CRLMs (2016–2021) across 17 hepatopancreatobiliary centers. Only patients with known KRAS/BRAF status and documented margin type were analyzed. Margins were classified as R0, parenchymal R1 (R1P) or vascular R1 (R1V). Results Among 1078 patients (592 wild-type, 451 KRAS-mutated, 35 BRAF-mutated), R1P resection was associated with significantly worse overall survival than R0 (53 % vs 61 %; p < 0.0001), with the greatest detriment observed in KRAS-mutated tumors. In contrast, R1V was not significant in all molecular subgroups. Consistently, R1P margins were associated with higher recurrence rates in both wild-type and mutated patients, including KRAS and BRAF subgroups. Conversely, R1V margin was not associated with higher recurrence risk. Conclusions In CRLMs, the prognostic relevance of surgical margins may depend on tumor biology. For BRAF/KRAS wild-type disease, R0 resection remains the preferred goal, whereas the role of wider margins in high-risk molecular subgroups requires further validation. Preoperative molecular profiling may support more individualized surgical planning.

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Comparison of learning curve difference of laparoscopist according to controller type of flexible scope during laparoscopic liver resection - Surgical Endoscopy

Background In laparoscopic liver resection (LLR), a skilled scopist is essential for maintaining a clear operative view. We evaluated the scopist’s expertise on surgical outcomes and whether the flexible scope controller type (conventional dual-lever versus joystick) influences the scopist’s learning curve. Methods We retrospectively reviewed LLRs performed by a single surgeon between December 2021 and March 2023. Patients with prior hepatectomy, Child–Pugh class B/C, concurrent extrahepatic abdominal surgery, or laparoscopic donor hepatectomy were excluded. Expert scopists (n = 2) had > 7 years of experience, whereas beginner scopists (n = 2) had < 6 months. Outcomes were compared by expertise and scope type. Learning curves were assessed using linear regression and CUSUM analysis of operative time over case sequence. Results Among 161 LLRs, 82 were performed with expert scopists and 79 with beginner scopists. Compared with the expert group, the beginner group had longer operative time (178.0 vs 139.5 min, p < 0.001), more intraoperative transfusions (8.9% vs 0%, p = 0.006), and a higher open conversion rate (6.3% vs 0%, p = 0.012). In 116 procedures using conventional scopes (experts, n = 57; beginners, n = 59), experts had shorter operative time (144.0 vs 178.0 min, p = 0.002) and fewer transfusions (0% vs 11.9%, p = 0.013). In 45 procedures using joystick scopes, operative time and transfusion rates did not differ significantly between expert and beginner scopists. In major hepatectomy, both groups showed decreasing operative time with joystick scopes. In minor hepatectomy, experts had shorter operative time with conventional scopes, whereas no significant difference was observed with joystick scopes. Conclusion This study demonstrated that the proficiency of laparoscopists can affect surgical outcomes. Moreover, newly learning laparoscopists may acquire proficiency more rapidly when using joystick-controlled laparoscopes compared to conventional ones. In procedures like minor hepatectomy, which are relatively simpler, it was confirmed that there is no significant difference in proficiency when compared to expert scopists.

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Impact of CYP2A6 Genotype on Survival Outcomes... : Annals of Surgery

Objective:To evaluate the impact of CYP2A6 genetic polymorphisms on survival outcomes in patients with pancreatic ductal adenocarcinoma (PDAC)...

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Association Between Intraoperative Cholangiogram... : Journal of the American College of Surgeons

Background:Intraoperative cholangiography (IOC) is widely used during cholecystectomy to define biliary anatomy and potentially reduce bile duct...

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Left-Sided Uncinate-First Approach as a Technical Adjunct in Robotic Pancreatoduodenectomy: Video-Based Technical Insights in Challenging Anatomy - Annals of Surgical Oncology

Background Uncinate process dissection and superior mesenteric artery (SMA) control represent critical steps in robotic pancreatoduodenectomy (RPD). However, the conventional right-sided uncinate-first approach may be technically demanding in patients with unfavorable anatomy, such as visceral obesity or bulky tumors. Methods This multimedia article presents a video-based demonstration of a left-sided uncinate-first approach in robotic pancreatoduodenectomy. Two illustrative operative scenarios are used to demonstrate technical nuances of SMA exposure and uncinate process dissection in challenging anatomic conditions. Results The right-sided approach for a morbidly obese patient demonstrated limited SMA exposure due to increased operative depth and visceral adiposity, requiring substantial traction to identify the correct dissection plane. Conversely, the left-sided approach enabled early vascular control through creation of a mesenteric window, providing direct access to the SMA and facilitating a controlled medial-to-lateral uncinate dissection along a relatively avascular plane. This approach reduced traction on the superior mesenteric vein (SMV) and improved visualization of the posterior dissection plane. In all cases, R0 resection was achieved. Conclusions The left-sided approach represents a feasible technical adjunct in robotic pancreatoduodenectomy. It may enhance SMA exposure and facilitate safer uncinate dissection in selected patients with challenging anatomy, particularly in obesity or bulky tumors. This strategy should be considered within the armamentarium of advanced robotic hepatopancreatobiliary surgery.

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Anatomic-Biologic Borderline Resectability Criteria Improve Recurrence Risk Stratification in Perihilar Cholangiocarcinoma - Annals of Surgical Oncology

Background Borderline resectability in perihilar cholangiocarcinoma (pCCA) has largely been defined anatomically, although anatomy alone may not capture oncologic risk. This study evaluated whether biologic burden improves recurrence stratification after curative-intent resection of pCCA. Methods Using an international, multi-institutional database, patients undergoing resection without neoadjuvant therapy for non-metastatic pCCA were identified. Literature-based borderline resectability was defined as lymph node metastasis with portal vein/hepatic artery involvement or Bismuth type IV disease. Using a 200-U/mL carbohydrate antigen (CA19-9) cutoff, a three-tier anatomic-biologic borderline resectable (AB-BR) grouping (low, intermediate, high) was derived. The outcome of interest was recurrence-free survival (RFS). Results Among 239 patients (median age, 67.0 years, interquartile range [IQR], 58.0–74.0 years), 38.9% (n = 93) of patients were anatomically borderline resectable (BR). The anatomy-only BR definition did not stratify RFS or overall survival (OS) (both p > 0.05), whereas CA19-9 ≥200 U/mL stratified 2 year RFS within both resectable (55.7% vs. 32.6%) and BR (44.5% vs. 25.3%) groups (all p < 0.05). Four-group analysis demonstrated overlap between resectable/high CA19-9 and BR/low CA19-9, supporting collapsing the categories into AB-BR tiers. The 2 year RFS was 55.7, 37.8, and 25.3% in the low-, intermediate-, and high-risk AB-BR groups, respectively (p = 0.002). The 2 year area under the curve (AUC) value was improved by AB-BR for RFS versus anatomy alone (0.612 vs 0.537). After multivariable adjustment, high-risk AB-BR remained independently associated with higher hazards of recurrence or death (adjusted hazard ratio, 1.86; 95% confidence interval, 1.15–3.00). Conclusion Anatomic BR alone provided limited prognostic stratification. Incorporating CA19-9 improved recurrence prediction and identified an intermediate-risk group not captured by anatomy alone, supporting biologic resectability in pCCA. The AB-BR framework may help move surgical decision-making beyond technical resectability alone toward more oncologically informed treatment selection.

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Integrated Evaluation of Survival, Surgical Conversion, and Toxicity for Induction Therapy in Initially Unresectable Colorectal Liver Metastases: An Individual Patient Data Network Meta-analysis - Annals of Surgical Oncology

Background Patients with initially unresectable colorectal cancer liver metastases (CRLM) could derive benefits from active induction regimens by increasing the likelihood of surgical conversion. However, the comparative benefit-risk profiles of currently available regimens remain unclear. We performed an individual patient data (IPD) and network meta-analysis (NMA) to compare the efficacy of active induction regimens. Patients and Methods IPD was reconstructed from randomized controlled trials (RCTs). The primary outcome was progression-free survival (PFS). Secondary outcomes included R0–1 resection rate, overall survival (OS), and grade ≥ 3 adverse events (AEs). Subgroup analyses were conducted according to KRAS/BRAF status and primary tumor sidedness. An entropy-weighted TOPSIS model was used to integrate efficacy and safety outcomes. Results Seven RCTs involving 1368 patients were included. IPD-based network analysis suggested that bevacizumab + triplet-chemotherapy was associated with the highest probability of improving R0-1 resection rate (0.99) and prolonging PFS (0.99). No significant differences in OS were observed among targeted therapy-based regimens. For patients with KRAS/BRAF wild-type tumors, cetuximab + doublet-chemotherapy is the only therapy performed better than chemotherapy in prolonging PFS. Bevacizumab + triplet-chemotherapy demonstrated superior efficacy among patients with KRAS/BRAF-mutant tumors. No significant PFS differences were observed among therapies in both left-sided and right-sided. Bevacizumab + doublet-chemotherapy demonstrated a more balanced benefit-risk profile with the highest Topsis scores (0.67). Conclusions Bevacizumab plus triplet chemotherapy improves disease control and surgical conversion benefits but is associated with greater toxicity. Bevacizumab plus doublet chemotherapy showed the most favorable benefit–risk balance and may represent an optimal compromise for patients with initially unresectable CRLM.

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Inpatient Palliative Care and Procedural Intensity in Patients with Hepatopancreatobiliary Cancers at the End of Life - Annals of Surgical Oncology

Background Hepatopancreatobiliary (HPB) malignancies are associated with high morbidity and frequent invasive procedures near the end of life. Although palliative care improves quality of life and goal-concordant care, its relationship with procedural burden in HPB cancers at the end of life remains poorly understood. We evaluated associations between inpatient palliative care and end-of-life procedural intensity in HPB malignancies. Methods We conducted a retrospective analysis of adult patients with HPB cancers admitted to a tertiary academic health system within 6 months of death between January 1, 2013, and December 31, 2024. Electronic health records and tumor registry data were analyzed through June 1, 2025. Patients were categorized by inpatient procedures and palliative care consultations. The primary outcome was the relationship between palliative care involvement and inpatient procedural burden. Multivariable logistic regression evaluated associations between palliative care timing and procedural characteristics. Results Among 2,848 patients, 1,373 (48.2%) underwent an inpatient procedure and 1,160 (40.7%) received palliative care consultation. From 2013 to 2024, palliative care utilization more than doubled, while end-of-life procedural rates remained constant. Palliative care involvement prior to any procedure was associated with lower odds of undergoing nonpalliative-intent procedures relative to palliative-intent procedures (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.51–0.98; P = 0.038). Conclusions End-of-life inpatient procedures were common in HPB malignancies and persisted despite increased palliative care utilization. Early palliative care involvement was associated with a greater proportion of palliative-type procedures, suggesting an association between earlier palliative care integration and procedural decision-making that may better align with patient quality of life and end-of-life priorities.

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Early Foley Catheter Removal after Segmental... : Annals of Surgery

Objective:To evaluate the safety of early Foley catheter removal after segmental colectomy with colovesical fistula (CVF) closure in patients with...

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A National Survey of Contracts, Compensation, and Workplace Culture Among Junior Surgical Oncologists - Annals of Surgical Oncology

Background The transition from surgical training to independent practice is challenging, and little quantitative data exist to guide junior surgeons on contracts and compensation. Qualitative evidence suggests compensation model type may influence workplace dynamics and attrition, but this has not been formally examined. Patients and Methods A cross-sectional survey of Society of Surgical Oncology members in their first 8 years of practice was conducted in October–November 2025 (n = 221; response rate = 20.2%). Outcomes included contract and compensation characteristics, attrition risk, and workplace collegiality. Results Respondents were 53% female, 68% non-Hispanic white, and 65% academic; 40% were within their first 2 years of practice. Most (69%) attempted contract negotiation and 79% succeeded in at least one domain. Nearly all (79%) had a guaranteed salary period (median 3 years), after which most transitioned to work relative value unit (wRVU)-based compensation. One in four respondents (25%) were considering leaving within the year; this rose to nearly 80% among those who strongly disagreed their compensation was fair (p < 0.01). Greater productivity emphasis was inversely associated with workplace collegiality (odds ratio 1.8 per standard deviation [SD] increase, 95% confidence interval [CI] 1.1–3.0; p = 0.02). Conclusions This national survey provides contract and compensation data for junior surgical oncologists and demonstrates associations between perceived compensation fairness and attrition risk, and between productivity-based compensation emphasis and workplace hostility. These findings suggest that how surgeons perceive their compensation—not merely its structure—may be a target for institutional efforts to improve retention and culture.

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Postoperative Complications and Long-Term Cardiovascular Risk After Gastrectomy for Gastric Cancer - Annals of Surgical Oncology

Background As survival after gastrectomy for gastric cancer improves, long-term noncancer outcomes such as cardiovascular disease (CVD) have become increasingly important. Whether postoperative complications are associated with long-term CVD risk remains unclear. Methods We conducted a nationwide, population-based cohort study using the Korea National Health Insurance Service database. Adults aged ≥ 20 years without prior CVD who underwent gastrectomy for newly diagnosed gastric cancer between 2006 and 2019 were included. Postoperative complications within 30 days were identified using ICD-10 codes and classified as pulmonary, surgical wound, gastrointestinal, urinary, or bleeding complications. The primary outcome was incident CVD, defined as myocardial infarction, stroke, heart failure, or cardiovascular death. Adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using multivariable Cox proportional hazards models. Results Among 3850 patients (median follow-up 5.3 years), 823 (21.4%) experienced postoperative complications and 162 developed CVD. The incidence rate of CVD was 12.1 and 7.0 per 1,000 person-years in patients with and without complications, respectively (absolute difference, 5.1 per 1000 person-years). Postoperative complications were associated with a higher risk of CVD (HR 1.63; 95% CI 1.15–2.30), even after adjustment for sociodemographic, clinical, and cancer-related factors. Pulmonary complications showed the strongest association, and the association was particularly evident for heart failure. Conclusions Postoperative complications after gastrectomy are associated with an increased long-term risk of CVD. These findings support closer cardiovascular surveillance and risk management in patients who experience postoperative complications.

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The Effect of Neoadjuvant Therapy on Post-Recurrence Overall Survival After Curative Resection for Intrahepatic Cholangiocarcinoma - Annals of Surgical Oncology

Background Despite the theoretical advantages of neoadjuvant therapy (NAT) in intrahepatic cholangiocarcinoma (iCCA), its impact on post-recurrence overall survival (PROS) remains poorly defined. This study investigated the association between NAT and post-recurrence outcomes. Methods This single-center retrospective study included consecutive patients with histologically confirmed iCCA who underwent curative-intent liver resection at Mayo Clinic Rochester (2000–2024). Neoadjuvant therapy was administered to selected patients with high-risk features. The association between NAT and PROS was evaluated using Kaplan-Meier analysis and multivariable Cox regression adjusted for relevant covariates. Results Among 343 patients with iCCA, NAT recipients were younger, more often treated in the contemporary era, and included a higher proportion of major resections. Targetable molecular alterations (IDH1, FGFR2) were markedly enriched in the NAT group (48.2% vs 13.9%). Neoadjuvant therapy was associated with significantly improved PROS (median, 31.9 vs 16.4 months; p = 0.006) and remained an independent predictor of survival on multivariable Cox regression (hazard ratio, 0.506; p = 0.008), even after the study accounted for era-dependent molecular-profiling. In contrast, older age and early recurrence were independently associated with worse PROS. Recurrence patterns, including location, timing, and median time to recurrence, remained comparable over time. After recurrence, NAT recipients more frequently underwent curative-intent local therapies and advanced systemic treatments. Conclusions Neoadjuvant therapy was associated with improved PROS for resected iCCA patients, consistent with a potential role in biologic selection. Recipients of NAT showed enriched targetable molecular alterations and better PROS despite stable recurrence patterns. These findings position PROS as a relevant endpoint in NAT-treated iCCA, complementing conventional survival metrics.

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Investigating Age-Related Differences in Survival Outcomes and Mutation Status of Patients with Intrahepatic Cholangiocarcinoma - Annals of Surgical Oncology

Background Survival outcomes for intrahepatic cholangiocarcinoma (IHC) remain poor due to late-stage presentation and limited effective treatment options. Previous studies have suggested age-related differences in outcome, but the results are mixed, and there is substantial variation in the definition of “young.” Methods A retrospective review analyzed 938 consecutive patients with a diagnosis of IHC between 2000 and 2018 at a single institution. Risk factors for IHC, clinical characteristics at diagnosis, and genomics were assessed for potential differences at the extremes of age (≤50 vs ≥70 years). Results The final cohort (n = 430) included 142 patients 50 years or younger and 288 patients older than 70. The most common genetic alterations were IDH1mut (22%), p53mut (17%), KRASmut (9.8%), and FGFR2fus (6.3%). Young patients had a higher proportion of FGFR2fus (p = 0.020). The median overall survival (OS) for the entire cohort was 23 months (95% confidence interval [CI], 20–27 months). In the resected group, recurrence-free survival (RFS) was longer for the older patients (median 27 vs 17months), but OS did not differ significantly (23 vs 25 months; p = 0.3). By contrast, among the unresectable patients, OS was significantly better for the younger patients (p = 0.008), but no significant relationship was observed between age and resection status when OS was assessed (p = 0.7). Conclusion Genomic differences between older and younger patients did not appear to drive the differences in OS observed in this cohort. Intrahepatic cholangiocarcinoma patients 50 years or younger likely do not represent a distinct subgroup despite differences in presentation and clinical characteristics.

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A novel bile leak test using contrast-enhanced intraoperative ultrasonic cholangiography in liver resection: a prospective single-arm trial - Surgical Endoscopy

Background Bile leak (BL) remains a major complication after liver resection and is associated with substantial postoperative morbidity. Conventional dye-based tests can identify visible leakage from the transection surface, but whether the injected reagent has adequately reached peripheral intrahepatic ducts adjacent to the cut surface is often uncertain. We evaluated the feasibility and safety of a novel BL test using contrast-enhanced intraoperative ultrasonic cholangiography (CE-IOUSC) for real-time confirmation of intrabiliary reagent filling. Methods This prospective single-arm trial included 29 patients undergoing open liver resection under the finalized protocol between March 2021 and February 2024. A reagent consisting of diluted Sonazoid, indigo carmine, and saline was injected through a cystic-duct catheter while the distal common bile duct was clamped. Ductal filling near the transection plane was assessed using contrast harmonic ultrasonography during and immediately after manual divided injection. Outcomes included technical success, postoperative BL, injection-related adverse events, and exploratory comparison of postoperative liver enzymes with a historical conventional-test cohort. Results CE-IOUSC testing was technically successful in 25 of 29 patients (86.2%). The median total injected volume was 5 mL (range 2–22 mL), and the median number of divided injections was 2 (range 1–6). Intraoperative BL was detected and sutured in 3 patients. Postoperative BL occurred in 5 patients (17.2%): 4 after technical success and 1 after technical failure. No adverse events related to intrabiliary reagent injection were observed. Postoperative AST and ALT elevations were significantly lower than in the historical cohort, although this comparison was exploratory. Conclusions CE-IOUSC-based BL testing was feasible and safe in open liver resection and enabled real-time confirmation of intrabiliary reagent filling near the transection surface. Its clinical efficacy in reducing postoperative BL or liver injury remains unproven and should be evaluated in future comparative studies.

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Clinical outcomes of plastic versus self-expanding metal stents in malignant hilar biliary obstruction - Surgical Endoscopy

Background Malignant hilar biliary obstruction (MHBO) is a challenging condition with a poor prognosis, often requiring palliative biliary drainage. Endoscopic placement of plastic stents (PS) or self-expanding metal stents (SEMS) are the preferred approaches, but the optimal choice remains under debate. This study compares the clinical outcomes, patency, and survival associated with PS and SEMS in patients with unresectable MHBO. Methods This retrospective study analyzed patients with MHBO who underwent endoscopic drainage between January 2015 and December 2022 at a tertiary cancer center. Clinical success, stent patency, survival, and reintervention rates were compared between patients receiving PS or SEMS. Cox proportional hazards models and Kaplan–Meier survival analyses were used to evaluate outcomes. Results A total of 86 patients were included, with 39 (45.3%) receiving SEMS and 47 (54.7%) receiving PS. Clinical success was higher in the SEMS group (76.9% vs. 51.1%; p = 0.015), but this association was not confirmed in multivariate analysis. SEMS demonstrated significantly longer patency (median 213 vs. 78 days; p = 0.01) and a lower risk of recurrent biliary obstruction (HR 3.17, 95% CI 1.60–6.27; p = 0.001). However, overall survival did not differ significantly between groups (p = 0.059). Multivariate analysis identified better ECOG status (0–2) and bilirubin levels < 10 mg/dL as independent predictors of clinical success and longer survival. Conclusion SEMS provide superior patency compared to PS but did not significantly impact overall survival. Clinical success was influenced by ECOG performance status and baseline bilirubin levels rather than stent type alone.

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The Landmark Series: Neoadjuvant Therapy for Patients with Resectable Gastroesophageal Junction Adenocarcinomas - Annals of Surgical Oncology

Neoadjuvant therapy is a cornerstone of treatment for resectable gastroesophageal junction (GEJ) tumors. Despite substantial advancements, optimal regimen selection remains challenging owing to heterogeneity in clinical trial inclusion criteria and treatment algorithms. This review synthesizes findings from pivotal randomized trials to guide evidence-based selection of neoadjuvant treatment for GEJ adenocarcinoma. In 2006, the MAGIC trial established a survival benefit with perioperative chemotherapy with epirubicin, cisplatin, and fluorouracil (ECF) compared with surgery alone. Subsequently, in 2012, CROSS demonstrated improved overall survival (OS) and R0 resection rates with neoadjuvant chemoradiotherapy (CRT) using carboplatin and paclitaxel compared with surgery alone. CRT increased pathologic complete response (pCR) rates and decreased local recurrence rates, though it had limited impact on distant recurrence rates. In 2018, the FLOT4 trial demonstrated that perioperative FLOT (fluorouracil, leucovorin, oxaliplatin, docetaxel) improved overall survival and pCR rates compared with ECF, making FLOT the new standard for perioperative chemotherapy. Several trials have since compared perioperative chemotherapy with neoadjuvant CRT. Neo-AEGIS found no survival difference; however, the predominance of ECF rather than FLOT in the chemotherapy arm limits its pertinence in the modern era. TOPGEAR demonstrated improved pCR with the addition of preoperative radiotherapy to FLOT, but no survival advantage. More recently, ESOPEC established FLOT’s superiority over CROSS for OS, and MATTERHORN demonstrated improved event-free survival with the addition of immunotherapy to perioperative FLOT. FLOT is the current standard for neoadjuvant treatment in GEJ adenocarcinoma due to its superior survival outcomes. Integration of immunotherapy represents a promising avenue to further improve outcomes.

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