Dr. Takeuchi and Kitagawa1 described the importance of artificial intelligence (AI) in surgical innovation. AI is rapidly gaining ground in various surgical fields worldwide. The current trajectory indicates that harnessing AI technologies can significantly improve patient care by reinforcing established practices and accelerating surgical innovation, offering a distinctive chance to explore potential advantages in providing health services to low- and middle-income countries (LMICs) globally. Large language models hold immense promise in revolutionizing medical education and emerging as indispensable assets in surgical practice. Medical students and surgeons could easily access a wealth of educational materials and clinical insights presented intuitively, enriching their understanding and proficiency.2 AI technologies have demonstrated their effectiveness in tailoring surgical training, streamlining administrative duties, and creating practical and affordable simulation training programs tailored to the specific needs of diverse individuals.3 Integrating machine learning algorithms in areas like big data analysis, computer vision, and operative robotics promises to revolutionize surgical patient risk assessment, surgical treatment, and postoperative monitoring, potentially enhancing patient outcomes through reductions in morbidity and mortality.4 More importantly, immediate intra-operative suggestions can assist surgeons in providing better evidence-based treatment to surgical patients. As the key players in this transformation, surgeons have the power to grasp the basic principles of AI, understand its implications in healthcare, and explore avenues for integrating this technology. Collaboration with data scientists to capture comprehensive data and provide clinical context is pivotal to optimizing surgical care quality. In the upcoming AI-driven era, it is crucial to prioritize AI's conscientious and ethical utilization. This should be underscored by vigilant monitoring of data governance and potential patient safety risks during deployment. The implementation process must also address usability, pathway feasibility, and the crucial need for thorough evaluation of healthcare technology and evidence generation. When these may be perceived as obstacles to AI adoption, holistic implementation strategies promise to establish a robust framework for the widespread integration of AI across healthcare systems, ensuring its responsible and ethical use. Global surgery encompasses a swiftly growing interdisciplinary domain dedicated to enhancing and ensuring fair access to quality surgical care within global healthcare frameworks. Initiatives within global surgery predominantly concentrate on bolstering capabilities, advocating for equitable access, facilitating educational programs, conducting research, and crafting policies tailored to the context of all countries. This is particularly significant for LMICs, where AI can potentially address deficiencies in surgical, anesthetic, and postoperative care, and is estimated to prevent 18 million mortalities annually, mainly in LMICs.5 It holds promise in providing insights for governance, infrastructure development, and logistics prediction, bolstering the foundational pillars of global surgery. The expansion of the interdisciplinary domain of AI in surgery brings with it a beacon of hope, aiming to bridge the gap in access to equitable quality of surgical care globally. Further research is imperative to ensure optimal and equitable AI utilization, overcoming obstacles such as data representativeness, training deficiencies, human hesitancy, and ethical considerations. Dealing with these challenges through a targeted, evidence-driven strategy could assist LMICs in surmounting bureaucratic inefficiencies and establishing improved surgical systems. N/A. The authors declare no conflicts of interest for this article. Approval of the research protocol: N/A. Informed consent: N/A. Registry and the Registration No. of the study/trial: N/A. Animal studies: N/A.

Due to the coronavirus disease 2019 (COVID-19) pandemic, cancer screening, diagnosis, and treatment have changed. This study aimed to investigate the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection prior to gastroenterological cancer surgeries on postoperative complications using data from a nationwide database in Japan. Data on patients who underwent surgery for cancer including esophageal, gastric, colon, rectal, liver, and pancreatic cancer between July 1, 2019, and September 300, 2022, from real-world sources in Japan were analyzed. The association between preoperative SARS-CoV-2 infection and short-term postoperative outcomes was evaluated. A similar analysis stratified according to the interval from SARS-CoV-2 infection to surgery (<4 vs. >4 weeks) was conducted. In total, 60 604 patients were analyzed, and 227 (0.4%) patients were diagnosed with SARS-CoV-2 infection preoperatively. The median interval from SARS-CoV-2 infection to surgery was 25 days. Patients diagnosed with SARS-CoV-2 infection preoperatively had a significantly higher incidence of pneumonia (odds ratio: 2.05; 95% confidence interval: 1.05-3.74; p = 0.036) than those not diagnosed with SARS-CoV-2 infection based on the exact logistic regression analysis adjusted for the characteristics of the patients. A similar finding was observed in patients who had SARS-CoV-2 infection <4 weeks before surgery. Patients with a history of SARS-CoV-2 infection had a significantly higher incidence of pneumonia. This finding can be particularly valuable for countries that have implemented strict regulations in response to the COVID-19 pandemic and have lower SARS-CoV-2 infection-related mortality rates.

The COVID era has ended as the pandemic subsided. It is anticipated that cancer care was hindered during the COVID era, which we expect had various negative effects. But what was the situation in actual clinical practice? Various reports have been published. In this issue, two reports have been made on the relationship between the treatment of gastrointestinal diseases and the pandemic. One is the impact of COVID-19 infection on colorectal perforation by Ogawa et al. They reported that among 13 107 cases of colorectal perforation, the 30-day postoperative mortality was 1371 cases (10.5%), and there was no difference compared to the pre-COVID era (DOI: 10.1002/ags3.12758). Furthermore, Akagi et al. clarified that the standard mortality rates for laparoscopic distal gastrectomy (LDG) for gastric cancer and laparoscopic low anterior resection (LLAR) for rectal cancer did not differ from the pre-COVID era, indicating that laparoscopic surgery was safely performed in Japan (DOI: 10.1002/ags3.12776). This editorial summarizes the impacts of the COVID era and pandemic on various gastrointestinal cancers by type of cancer. Colorectal Cancer: 48 900 CRC patients were extracted from the Dutch cancer registry. Compared to the same period before COVID, CRC patients decreased by up to 36%. In particular, during the first peak (weeks 12–20 of 2020), Stage I decreased by 4%, while Stage IV increased by 7%.1 In Japan, it has also been reported that the number of CRC screening participants has not returned to the pre-pandemic levels, with decreases of −13.4% (2020) and −7.3% (2021).2 Gastric Cancer: A single institution in Korea compared a pre-pandemic surgical group (99 cases) with a during-pandemic group (118 cases) and found that while short-term outcomes and long-term complications were equivalent, perioperative outcomes were poorer during the pandemic.3 Takeuchi and colleagues observed a decrease in 568 cases of gastrectomy. However, they reported that mortality and perioperative outcomes during the pandemic did not worsen compared to before the pandemic.4 Esophageal Cancer: In the UK, diagnoses, management, and outcomes of esophageal cancer were investigated before and after the COVID-19 lockdown. Overall survival was 9.9 months before the lockdown and 6.9 months after, significantly worse post-lockdown.5 It is speculated that this was due to delayed examinations during the lockdown, leading to esophageal cancer being detected at more advanced stages. However, reports from Japan indicated similar (not inferior) outcomes to pre-COVID times, despite limited medical resources.6 Liver Cancer: Munoz-Martinez and colleagues reported a 2.2% decrease in mortality rates for HCV (and HBV)-related HCC, while mortality rates for NAFLD (alcohol-related liver disease)-related hepatocellular carcinoma increased by 3%. Delays in diagnosis were reported at 80.9%. Additionally, the 30-day mortality was 15% for SARS-CoV-2-related deaths, compared to 3.7% for non-SARS-CoV-20related deaths.7 Pancreatic Cancer: During the lockdown, referral rates decreased by 29%. However, there were no differences in metastasis rates (p = 0.39), TNM (p = 0.80), or treatment choices (p = 0.94) between pre-pandemic and during-pandemic periods. Moreover, there was no significant difference in the 1-year survival rate between pre-pandemic (2019) and during-pandemic (2020–21) periods for surgery, chemotherapy, or best supportive care (BSC).8 In summary, the consultation and referral rates for patients with gastrointestinal cancer decreased due to the pandemic, and early diagnosis was delayed. For all cancer types, those global delays in screening, diagnosis, and treatment will potentially lead to an increase in cancer-related deaths in the future, therefore, we need to have a necessitating careful long-term observation. Most of the reports indicated that the perioperative management of gastrointestinal cancers in Japan was excellent generally, with no difference in safety before and after the pandemic. I would like to thank Drs. C. Matsumoto, A. Ofuchi, K. Hosada, T. Ikehara, and S. Higuchi for collecting data. The author declare no conflicts of interest for this article.

The aim of this study was to clarify the significance of blood culture testing in the postoperative period of pancreatoduodectomy (PD), a highly invasive surgery. Rates of blood culture sampling and positivity were investigated for febrile episodes (FEs) in patients who underwent PD (2016-2021). FEs were defined as body temperature of 38.0°C or higher occurring on or after the 4th postoperative day. Fever origin was diagnosed retrospectively, and FEs were classified as pancreatic fistula (PF)-related or PF-unrelated FEs. Factors correlated with blood culture positivity were explored. Among 339 patients who underwent PD, 99 experienced 202 FEs. Blood culture testing was performed on 160 FEs occurring in 89 patients. The sampling and positivity rates were 79.2% and 17.5%, respectively, per episode and 89.9% and 28.1%, respectively, per patient. Thirty-six FEs were classified as PF-related and 124 were classified as PF-unrelated FEs. The blood culture positivity rate was significantly lower in PF-related vs. PF-unrelated FEs (1/36 vs. 27/124, respectively, p = 0.006). The blood culture positivity rate was significantly higher in patients with cholangitis, catheter-related blood stream infection, and urinary tract infection than PF-related FEs. Multivariate analysis showed that blood culture positivity was negatively associated with PF-related FEs and positively associated with accompanying symptoms of shivering, Pitt Bacteremia Score, and preoperative biliary drainage. Patients who underwent PD showed relatively high blood culture positivity rates. Based on these results, it may be possible to distinguish PF-related and -unrelated FEs.

This study aimed to evaluate the efficacy of lateral lymph node dissection (LLND) for rectal cancer by comparing the local control in patients with and without pathological lateral lymph node metastasis (LLNM). We included 189 patients with rectal cancer who underwent total mesorectal excision and LLND at 13 institutions between 2017 and 2019. Patients with and without pathological LLNM were defined as the pLLNM (+) and (-) groups, respectively. Propensity score-matching helped to balance the basic characteristics of both groups. The incidences of local recurrence (LR) and lateral lymph node recurrence (LLNR) were compared between the groups. In the entire cohort, 39 of the 189 patients had pathological LLNM. The 3-year LR and LLNR rates were 18.3% and 4.0% (p = 0.01) and 7.7% and 3.3% (p = 0.22) in the pLLNM (+) and (-) groups, respectively. After propensity score matching, the data from 62 patients were analyzed. No significant differences in LR or LLNR were observed between both groups. The 3-year LR and LLNR rates were 16.4% and 9.8% (p = 0.46) and 9.7% and 9.8% (p = 0.99) in the pLLNM (+) and (-) groups, respectively. LLND would lead to comparable local control in the pLLNM (+) and (-) groups if the clinicopathological characteristics except for LLNM are similar.

Abstract BackgroundZinc (Zn), an essential trace element, has an adverse influence on the prognosis of several cancers. However, the association between the preoperative serum Zn level and outcomes in patients with advanced esophageal cancer in the current neoadjuvant treatment era remains unclear.MethodsThis study involved 185 patients with esophageal cancer who underwent R0 surgery after neoadjuvant chemotherapy from August 2017 to February 2021. We retrospectively investigated the relationship between the preoperative serum Zn level and the patients' outcomes.ResultsThe patients were divided into a low Zn group (&lt;64 μg/dL) and a high Zn group (≤64 μg/dL) according to the mean preoperative serum Zn level. Low Zn had significantly worse overall survival (OS) (2‐year OS rate: 76.2% vs. 83.3% in low vs. high Zn; p = 0.044). A low Zn in pathological non‐responders (Grade ≤ 1a) was significantly associated with a shorter 2‐year recurrence‐free survival (RFS) rate (39.6% vs. 64.1% in low vs. high Zn; p = 0.032). The multivariate analysis identified low BMI and Zn level among preoperative nutritional status indices as an independent risk factor for worse RFS in non‐responders. Compared with responders, pathological non‐responders comprised significantly more males and a performance status of ≥1, and there was no difference in Zn level according to pathological response.ConclusionA preoperative low Zn level had a negative impact on early recurrence in esophageal cancer patients who underwent neoadjuvant chemotherapy. This suggests the need to administer Zn supplementation to patients with esophageal cancer who have preoperative Zn deficiency.

PurposeThis study aims to explore the role of circ_0032704 in sorafenib‐resistant hepatocellular carcinoma (HCC).MethodsThe expression of circ_0032704, miR‐514a‐3p, and programmed death‐ligand 1 (PD‐L1) mRNA was detected by quantitative real‐time PCR (qPCR). The expression of multidrug resistant‐related proteins, migration/invasion‐related proteins, exosome‐related proteins, and PD‐L1 protein was detected by western blot. Cell viability was detected by CCK‐8 assay. Cell proliferation, migration, and invasion were assessed by EdU assay, wound healing assay, and transwell assay. The binding between miR‐514a‐3p and circ_0032704 or PD‐L1 was verified by RIP assay, pull‐down assay, and dual‐luciferase reporter assay. Cell‐ or serum‐derived exosomes were isolated and identified by TEM and NTA. Xenograft models were established to determine the effect of circ_0032704 on drug resistance in vivo.ResultsCirc_0032704 was overexpressed in sorafenib‐resistant HCC tissues and cells. Circ_0032704 knockdown reduced sorafenib resistance in HCC cells and inhibited cell proliferation, migration, and invasion of sorafenib‐resistant HCC cells, while these effects were reversed by PD‐L1 overexpression. We found that circ_0032704 positively regulated PD‐L1 expression via targeting miR‐514a‐3p. Exosomes with circ_0032704 inhibition reduced sorafenib resistance in HCC cells and inhibited cell proliferation, migration, and invasion of sorafenib‐resistant HCC cells. Exosomes with circ_0032704 inhibition also inhibited tumor growth in vivo. The expression of circ_0032704 in exosomes was stable and possessed diagnostic value.ConclusionCirc_0032704 enhanced sorafenib resistance in HCC and promoted the malignant development of sorafenib‐resistant HCC. Circ_0032704 could be transported by exosomes, and exosomal circ_0032704 had diagnostic value.

BackgroundWe aimed to identify the characteristics of new‐onset diabetes after liver transplantation (LT) (NODAT) and investigate its impacts on post‐transplant outcomes.MethodsAdult LT patients between 2014 and 2020 who used tacrolimus as initial immunosuppression and survived 3 months at least were evaluated. Patients who developed NODAT within 3 months after LT were classified as NODAT group. Also, patients were further classified as history of diabetes before LT (PHDBT) and non‐diabetes (ND) groups. Patient characteristics, post‐LT outcomes, and cardiovascular and/or pulmonary complications were compared.ResultsA total of 83, 225, and 263 patients were classified into NODAT, PHDBT, and ND groups. The proportion of cholestatic liver disease and rejection within 90 days were higher in NODAT group. Mean serum tacrolimus concentration trough level in the first week after LT was 7.12, 6.12, and 6.12 ng/mL (p < 0.001). Duration of corticosteroids was significantly longer in NODAT compared to PHDBD or ND (416, 289, and 228 days, p < 0.001). Three‐year graft and patient survival were significantly worse in NODAT than ND (80.5% vs. 95.0%, p < 0.001: 82.0% vs. 95.4%, p < 0.001) but similar to PHDBT. Adjusted risks of 3‐year graft loss and patient death using Cox regression analysis were significantly higher in NODAT compared to ND (adjusted hazard ratio [aHR] 3.41, p = 0.004; aHR 3.61, p = 0.004). Incidence rates of cardiovascular or pulmonary complications after LT in NODAT were significantly higher than ND but similar to PHDBT.ConclusionHigher initial tacrolimus concentration and early rejection might be risk factors for NODAT. NODAT was associated with worse post‐transplant outcomes.

Operations for malignant diseases of the bile duct, pancreas, and esophagus are the most invasive gastroenterological surgeries. The frequency of complications after these surgeries is high, which affects the postoperative course and mortality. In patients who undergo these types of surgeries, continuous monitoring of the perioperative central venous oxygen saturation (ScvO2) is possible via a central venous catheter. We aimed to investigate the relationship between continuously monitored perioperative ScvO2 values and postoperative complications. The medical records of 115 patients who underwent highly invasive gastroenterological surgeries and ScvO2 monitoring from April 2012 to March 2014 were analyzed. Sixty patients met the inclusion criteria, and their ScvO2 levels were continuously monitored perioperatively. The relationship between ScvO2 levels and major postoperative complications, defined as Clavien-Dindo grade ≥ III, was examined using uni- and multivariate analysis. Thirty patients developed major postoperative complications. The adequate cut-off value derived from receiver operating curves of the postoperative average ScvO2 levels for predicting major complications was 75%. Multivariate analysis revealed that low average postoperative ScvO2 levels (p = 0.016) and blood loss ≥ 1000 mL (p = 0.039) were significant predictors of major postoperative complications. Low perioperative ScvO2 values were associated with an increased risk of major postoperative complications. Continuous ScvO2 monitoring will help prevent postoperative complications.