ABSTRACT Background Despite improvements in surgical techniques and perioperative management, the incidence of postoperative surgical site infection after pancreatoduodenectomy remains high. This study aim to assess whether broad‐spectrum antibiotic prophylaxis can reduce complications after pancreatoduodenectomy compared with standard care antibiotics. Methods Data of patients who underwent pancreatoduodenectomy between July 2010 and March 2022 were extracted from a nationwide Japanese inpatient database. First‐ and second‐generation cephalosporins were designated as narrow‐spectrum, and third‐ and fourth‐generation cephalosporins and piperacillin–tazobactam as broad‐spectrum antibiotics. Patients who received either narrow‐ or broad‐spectrum antibiotics on the day of surgery were included in the analysis. Using propensity‐score stabilized inverse probability of treatment weighting, the postoperative complications were compared between patients who received antimicrobial prophylaxis with narrow‐spectrum antibiotics versus broad‐spectrum antibiotics. Results From among 45 099 eligible patients, 36 742 (81.5%) and 8357 (18.5%) patients received narrow‐ and broad‐spectrum antibiotics, respectively. After stabilized inverse probability of treatment weighting, the use of broad‐spectrum antibiotics bore a significant association with the reduction in intra‐abdominal infections [risk difference (RD), −7.4; 95% confidence interval (CI), −8.7 to −6.0], postoperative pancreatic fistula (RD, −3.0; 95% CI, −4.0 to −1.9), post‐pancreatectomy hemorrhage (RD, −1.5; 95% CI, −1.9 to −1.1). The use of broad‐spectrum antibiotics was also associated with a shorter postoperative length of hospital stay and lower total hospitalization costs. The proportion of Clostridioides difficile infection did not differ between the groups. Conclusions The administration of broad‐spectrum antibiotics as antimicrobial prophylaxis was associated with better in‐hospital postoperative outcomes compared with narrow‐spectrum in patients undergoing pancreatoduodenectomy.

ABSTRACT Background This study aimed to examine whether preoperative serum total iron‐binding capacity (TIBC), which is directly proportional to transferrin level, correlates with short‐ and long‐term outcomes after hepatectomy. Methods Preoperative TIBC levels, calculated by summing serum iron and unsaturated iron binding capacity, were evaluated in 577 patients who underwent hepatectomy for hepatocellular carcinoma. We defined TIBC < 274 μg/dL calculated by receiver‐operating characteristic (ROC) analysis as low TIBC. We evaluated the relationship between preoperative TIBC levels and short‐ and long‐term outcomes after hepatectomy. Results Low preoperative TIBC levels were correlated with lower body mass index, worse Child Pugh score, lower albumin, higher CRP, lower hemoglobin, lower serum iron, higher controlling nutritional status (CONUT) score, lower prognostic nutritional index (PNI), and larger tumor size compared to those in high TIBC levels ( p = 0.0070, 0.0098, < 0.0001, 0.0008, 0.0086, 0.0018, 0.0008, < 0.0001, and 0.016, respectively). Patients with low preoperative TIBC levels experienced significantly more frequent postoperative complications of Clavien–Dindo classification (CDc) ≥ II and III in univariate and multivariate analyses (CDc≥II; hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.010–2.799, p = 0.046/CDc≥III; hazard ratio [HR] 1.92, 95% confidence interval [CI] 1.015–3.506, p = 0.045). Furthermore, these patients were significantly correlated with worse overall survival (OS) and relapse free survival (RFS) in univariate and multivariate analyses (OS; HR 3.24, 95% CI 1.783–5.805, p = 0.0002/RFS; HR 1.65, 95% CI 1.009–2.720, p = 0.046). Conclusion Preoperative serum TIBC levels may be a novel surrogate marker of postoperative complications and long‐term survival after hepatectomy.

ABSTRACT Background Although NCCN guidelines recommend preoperative therapy for borderline resectable pancreatic cancer (BR‐PC), it is still unclear which regimen is better. The study objective was to elucidate the prognostic significance of neoadjuvant chemoradiotherapy (NACRT) with gemcitabine/nab‐paclitaxel (GnP‐RT) compared to gemcitabine alone (Gem‐RT) in BR‐PC. Methods Of 201 patients with BR‐PC enrolled in the study, 102 were receiving GnP‐RT and 99 were receiving Gem‐RT. We evaluated clinical outcomes between these two groups, including CA19‐9 values, rate of tumor reduction, overall (OS) and progression‐free survival (PFS) rates, and distant and local recurrence. Results CA19‐9 values and tumor size reduction rate after NACRT were significantly higher with GnP‐RT than with Gem‐RT. With GnP‐RT, the 5‐year OS rate was 55.2% and the PFS rate was 42.1%, both significantly better than rates with Gem‐RT (OS, 35.4%, p = 0.006; PFS, 31.9%, p = 0.041). The incidence of distant recurrence with GnP‐RT was significantly lower than with Gem‐RT ( p = 0.018), but the incidence of local recurrence did not differ between the two groups ( p = 0.905), indicating that the better survival with GnP‐RT might arise from a systemic effect of enhanced chemotherapy. Conclusion Enhanced chemotherapy may improve survival in patients with BR‐PC by suppressing distant metastasis through a potent systemic antitumor effect.

ABSTRACT Esophageal cancer surgery is evolving from technical standardization to a paradigm of personalized, strategy‐oriented care. Robotic‐assisted techniques and enhanced perioperative protocols have improved safety, but the field is increasingly shaped by three forces: integration of immune checkpoint inhibitors (ICIs), population aging, and the rise of intelligent technologies such as artificial intelligence (AI) and extended reality. Adjuvant nivolumab after neoadjuvant chemoradiotherapy (nCRT) remains the standard for residual disease, while other regimens such as durvalumab or dual checkpoint blockade have not demonstrated consistent survival benefit. Neoadjuvant ICI strategies, particularly camrelizumab plus chemotherapy in esophageal squamous cell cancer (ESCC), achieve high pathological response rates without increasing surgical morbidity, and pooled analyses confirm their feasibility. Immune‐related adverse events (irAEs) occur in approximately 20%–35% of patients but are usually manageable. Perioperative outcomes remain comparable to conventional regimens. Elderly and frail patients require individualized optimization. The integration of minimally invasive techniques, assessment of sarcopenia and nutritional risk, and adjustment of chemotherapy intensity have contributed to improved outcomes. Moreover, salvage surgery—once prohibitive—now offers meaningful long‐term survival when performed in high‐volume centers with specialized expertise. AI and machine learning are transforming risk stratification, intraoperative guidance, and surgical training. AI‐assisted video analytics and VR/AR simulators enhance skill acquisition, credentialing, and standardization. Future progress will depend on multicenter validation, prospective registries, and integration of oncologic, physiologic, and technological variables. Ultimately, the future of esophageal cancer surgery will be defined not only by technical precision but also by the surgeon's ability to leverage data‐driven innovation for personalized care.

ABSTRACT Background The prognostic impact of prior cholecystectomy (CCY) in patients with colorectal cancer (CRC) remains uncertain. The aim of this study was to evaluate the prognostic impact of prior CCY in a large cohort of patients with CRC, with particular attention to tumor location. Methods We retrospectively analyzed all patients diagnosed with colorectal adenocarcinoma between January 2012 and December 2023. Patients were classified into proximal (cecum, ascending, and transverse) and distal (descending, sigmoid, and rectum) groups. Survival outcomes were compared using multivariate Cox proportional hazards regression models, including an interaction term between tumor location and history of CCY. Propensity score matching (PSM) was performed as a sensitivity analysis. Results Among 3487 patients (1375 proximal and 2112 distal CRC), 158 (4.8%) had a history of CCY. Proximal CRC was more frequently associated with female sex, older age, history of CCY, poor differentiation, BRAF mutation, MSI‐high status, and non‐resection initial strategy ( p ≤ 0.005). Among proximal CRC patients, multivariate analysis revealed TNM stage III/IV ( p < 0.001), non‐resection initial strategy ( p < 0.001), and history of CCY ( p = 0.042) were independent predictors of poor overall survival (OS). Prior CCY was associated with worse OS in proximal CRC ( p = 0.004). A significant interaction between tumor location and history of CCY was observed ( p for interaction = 0.025). Conclusions History of CCY was associated with worse prognosis in proximal CRC but not in distal CRC, suggesting a differential impact of CCY on prognosis in CRC. Our findings would provide insight into further research on bile acid metabolism or microbiome modulation in CRC patients.

ABSTRACT Aim Posthepatectomy liver failure (PHLF) is a serious complication of major hepatectomy and is closely related to perioperative mortality. Whether or not indocyanine green (ICG) is used to measure liver function varies by country. Using machine learning, we aimed to develop two highly accurate, user‐friendly models for predicting PHLF depending on whether ICG data were used. Methods This was a retrospective, three‐center study. SHapley Additive exPlanations (SHAP) evaluated the feature importance of Random Forest (RF) analysis. SHAP quantitatively assessed the impact of each feature on model predictions and identified the three most important features in both ICG‐used and ICG‐unused models. A Decision Tree (DT) model was constructed using two of these three key features to enhance clinical interpretability. PHLF was defined as Grade B or C according to the International Study Group of Liver Surgery. Results Feature importance was calculated using the SHAP analysis, in the ICG‐used model the ICG clearance rate (ICGK) multiplied by the percentage of remaining liver measured by CT volumetry (ICGK‐F), CRP, and operative procedure were identified as the three highest factors, whereas the predicted liver resection rate, CRP, and total bilirubin were identified as the most important features in the ICG‐unused model. In the constructed DT model, we categorized the cases into negative and positive, and the negative cases were further classified into three categories based on their risks. Conclusion These models may offer a simple and practical approach for predicting the risk of PHLF and hold promise for future clinical application.

In cancer patients, malnutrition worsens postoperative outcomes, with increased complications and poor prognosis. We aimed to update the impact of malnutrition, as defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria, on postoperative outcomes in patients with gastroenterological cancer after curative resection. We identified observational studies published from inception to April 2, 2025. A systematic review and random-effects meta-analysis were performed on studies including adult patients (age > 18 years) with gastroenterological cancer who received surgical treatment and had nutritional status assessments based on GLIM criteria. The primary outcomes were overall survival (OS) and overall postoperative complications, which were defined as events with a Clavien-Dindo (CD) grade ≥ II that occurred within 30 days after surgery. Hazard ratios and relative risk ratios for OS and postoperative complications, respectively, with 95% confidence intervals were pooled. The protocol has been published in PROSPERO (CRD42023434267). Twenty-five studies (28 reports comprising 10 942 patients) were included in the qualitative and quantitative syntheses. Compared with the absence of malnutrition, GLIM-defined malnutrition probably worsens OS (hazard ratio: 1.88, 95% concordance interval: 1.62-2.18, certainty of the evidence: low) and increases postoperative complications (relative risk ratio: 1.57, 95% concordance interval: 1.34-1.84, certainty of the evidence: low). The risk of bias in each study was moderate or high. GLIM-defined malnutrition probably worsens OS and increases the risk of postoperative complications in patients with gastroenterological cancer after surgery.

ABSTRACTAimIncrease in surgical patients undergoing antithrombotic therapy (ATT) has intensified the concerns regarding perioperative bleeding and thromboembolic complications. This study evaluated the safety of hepatectomy in patients receiving ATT, with a focus on those receiving dual therapy.MethodsWe retrospectively analyzed 749 patients who underwent elective hepatectomies between 2011 and 2024. Among them, 140 received ATT according to the Japanese guidelines, and 98 were matched 1:1 with non‐ATT controls using propensity scores. The primary outcome was major morbidity, defined as Clavien–Dindo ≥grade III; intraoperative blood loss and transfusion requirement were secondary outcomes. Outcomes were also compared across the ATT regimens, including dual therapy (antiplatelet plus anticoagulants).ResultsCompared with the non‐ATT group, the ATT group had a significantly longer operative time (median, 318 vs. 250 min; p = 0.019), while blood loss (355 vs. 300 mL; p = 0.460), transfusion rate (19.4% vs. 23.5%; p = 0.602), and severe complication rate (32.7% vs. 22.4%; p = 0.150) were not significantly different. Post‐hepatectomy liver failure (PHLF) incidence (16.3% vs. 13.3%) and median hospital stay (13 vs. 12 days) were also comparable. In subgroup analysis, patients receiving dual therapy exhibited higher complication rates, including hemorrhagic events (30%), Clavien–Dindo≥grade III (40%), and PHLF (50%), exceeding the rates seen in monotherapy groups.ConclusionHepatectomies can be safely performed in patients receiving well‐managed ATT. However, dual therapy was associated with higher rates of perioperative complications, including bleeding and PHLF, compared with monotherapy or no ATT, underscoring the need for heightened caution and individualized management in this high‐risk group.

ABSTRACTAimAlthough perforated colorectal cancer has a poor prognosis, it remains unclear whether this is attributed to the perforation itself or related clinicopathological factors indicating advanced tumor progression. We investigated the true prognostic impact of perforation in colorectal cancer after adjusting for perforation‐related clinicopathological factors.MethodsThis retrospective single‐center cohort study included 2073 patients underwent curative resection for primary colorectal cancer between January 2009 and December 2022 (73 with perforated colorectal cancer and 2000 with nonperforated colorectal cancer). Perforation‐related clinicopathological factors were identified by multivariate logistic regression and used for 1:2 propensity score matching as covariates. Recurrence‐free survival and overall survival were analyzed using Kaplan–Meier estimates and Cox proportional hazards models.ResultsIndependent perforation‐related clinicopathological factors were age ≥ 75 years, left‐sided tumor, and pathological T Stage 4 (pT4). The perforated colorectal cancer group had a lower rate of minimally invasive surgery (62.5% vs. 90.6%), fewer harvested lymph nodes (medians: 13 vs. 16.5), and more frequent major postoperative complications (18.8% vs. 7.3%) compared to the nonperforated colorectal cancer group. Multivariate Cox analysis revealed that pT4 and perforation independently predicted worse recurrence‐free survival and overall survival. The hazard ratios were 2.71 and 2.54 for pT4 (95% confidence intervals: 1.45–5.04 and 1.08–5.9), and 2.67 and 3.30 for perforation (95% confidence intervals: 1.44–4.96 and 1.37–7.96), respectively.ConclusionPerforation independently predicted poor prognosis in colorectal cancer, highlighting its distinct oncologic relevance beyond standard pathological staging. Prospective studies should establish individualized strategies to improve outcomes in perforated colorectal cancer.

ABSTRACTAimThis study evaluated preoperative psoas muscle volume, measured by plain computed tomography, as an independent predictor of short‐term postoperative outcomes in patients undergoing surgery for strangulated small bowel obstruction, and examined the impact of postoperative complications.MethodsThis retrospective, single‐center study included 107 patients who underwent emergency strangulated small bowel obstruction surgery between January 2013 and December 2024. Demographics, clinical and surgical variables, laboratory values, and outcomes were reviewed. Psoas muscle volume, subcutaneous fat area, visceral fat area, and psoas muscle index were measured on preoperative computed tomography.ResultsReceiver operating characteristic analysis identified 45.4 as the optimal psoas muscle volume cutoff, dividing patients into high (≥ 45.4) and low (< 45.4) groups. The low psoas muscle volume group was older, with lower BMI, nutritional indices, and serum albumin. Complications occurred more frequently in the low psoas muscle volume group, most commonly pneumonia. Severe complications (Clavien–Dindo ≥ III) were confined to patients aged ≥ 75 years, predominantly with low psoas muscle volume. Multivariate analysis identified advanced age and low psoas muscle volume as independent risk factors. Complications were associated with delayed bowel recovery, longer hospitalization, and reduced home‐discharge rates. Low psoas muscle volume independently predicted cardiopulmonary and systemic complications but not infectious or gastrointestinal complications.ConclusionAdvanced age and low psoas muscle volume independently predicted postoperative complications. Low psoas muscle volume was particularly linked to cardiopulmonary and systemic events, highlighting the need for preoperative risk stratification and early multidisciplinary management in older adults having strangulated small bowel obstruction with reduced muscle mass.Trial RegistrationNot applicable