IntroductionEmergency laparotomy (EL) remains one of the highest-risk procedures in general surgery, characterized by substantial postoperative morbidity and...

Objectives Pancreatoduodenectomy (PD) is a highly invasive surgery that raises concerns about postoperative loss of independence (LOI), a critical outcome defined as a decline in activities of daily living (ADL). LOI reflects a significant shift in functional status, often requiring additional care such as rehabilitation or home-based healthcare. While reducing complications and mortality is prioritized, maintaining a preoperative lifestyle remains underexplored. Therefore, this study aimed to elucidate the risk factors of LOI after PD. Methods We retrospectively analyzed 215 patients underwent PD between August 2017 and April 2024. Patients were classified into young (< 65 years) and elderly groups (≥ 65 years). Using univariate and multivariate analyses, we assessed risk factors of LOI after PD. Results There was no incidence of LOI in the young group, whereas 22 patients (16.7%) developed LOI in the elderly group. Univariate analysis revealed that age ≥ 80 years (P < 0.001), sarcopenia (P < 0.001), open surgery (P = 0.013), and malignant disease (P = 0.009) were the risk factors of LOI. Multivariate analysis identified age ≥ 80 years (P < 0.001), sarcopenia (P < 0.001), and open surgery (P = 0.040) as the independent risk factors of LOI in the elderly group. Using these three factors, we established LOI score. This LOI score significantly correlated with the incidence of LOI (P < 0.001). Conclusions This is the first study to identify the risk factors of LOI after PD. It may help the decision-making regarding MIS surgery with other risk factors in clinical practice. Graphical abstract

We report the results of a consensus exercise covering the basics of management of peritoneal mesothelioma (PeM) (diagnostic evaluation, patient selection for each therapeutic modality) and some technical aspects of cytoreductive surgery (CRS) and use of intraperitoneal treatments. The modified Delphi method was employed with two rounds of voting. There were 27 questions on eight topics: diagnostic tests/preoperative work-up, extent of CRS, role of regional lymphadenectomy, hyperthermic intraperitoneal chemotherapy (HIPEC) regimens, perioperative systemic chemotherapy, role of other forms of intraperitoneal chemotherapy, surveillance after CRS-HIPEC, iterative CRS and role of palliative systemic chemotherapy. A consensus was achieved if any one option received > 70% votes (strong consensus > 90%). In round 1, 41/45 (91.11%) and in round 2, 39/45 (86.67%) panelists voted. A consensus was achieved on 22/27 (48.14%) questions (strong consensus: 33.33%). Hundred percent panelists agreed that CRS-HIPEC should be the standard-of-care for newly diagnosed PeM if the disease is completely resectable, and there is no contraindication to surgery. The panel reinforced some important recommendations of existing international guidelines on PeM, including using the cisplatin–doxorubicin combination for HIPEC, performing a total parietal peritonectomy systematically for all patients and offering neoadjuvant chemotherapy to patients with sarcomatoid and biphasic histological subtypes and for patients with PCI > 17 and Ki-67 > 9%. A consensus was reached on the indications for perioperative systemic chemotherapy. A “strong” consensus was achieved on several important issues related to the management of PeM. The treatment algorithm provided here should a useful tool to aid clinical decision making for Indian clinicians treating PeM.

Background Recurrent common bile duct (CBD) stones after endoscopic retrograde cholangiopancreatography (ERCP) is a significant clinical issue. While the association between serum lipid levels and gallstones has been established, its impact on recurrent CBD stone is less clear. This study aims to investigate the association between serum lipid levels and recurrent CBD stone, further subclassified into different subgroups. We also try to explore effective drugs to decrease the occurrence of recurrent CBD stone. Materials and Methods This multi-institutional study acquired patients’ data from Chang Gung Memorial Hospitals using Chang Gung Research Database (CGRD) from 2002/1/1 to 2020/12/31. We analyzed the association between metabolic risk factors and recurrent CBD stone after ERCP using propensity score matching and then subclassified these patients into cholecystectomy, cirrhosis, and hyperlipidemia. Additionally, medications aimed at controlling serum lipid levels were investigated for their potential to reduce the recurrence rate of CBD stones. Results Totally, 5132 patients were enrolled. Our results showed that higher cholesterol level and HbA1C above 6.5% are risk factors of CBD stone recurrence after ERCP when using propensity score matching. However, triglyceride (TG) and high-density lipoprotein (HDL) were presented as protective factors. These metabolic factors may be variable in different subgroups. Additionally, statin and aspirin might be effective drugs to reduce CBD stone recurrence rate. Conclusions Serum lipid level and HbA1C were found to be associated with recurrent CBD stone after ERCP but variable in different subgroups. Statin and aspirin might reduce the risk of CBD stone recurrence.

Introduction Enhanced Recovery After Surgery (ERAS) protocols are multimodal, evidence-based pathways designed to accelerate postoperative recovery and reduce complications. A key component of ERAS is optimizing pain management to minimize opioid reliance. Ketamine, an NMDA receptor antagonist, has demonstrated potential as a multimodal analgesic for reducing opioid consumption and postoperative pain; however, its specific role and efficacy within comprehensive ERAS protocols remain under-evaluated, with variations in dosing and patient response. The current literature lacks a clear consensus on the efficacy of postoperative ketamine infusion for critical ERAS outcomes, including pain control, opioid consumption, postoperative nausea and vomiting (PONV), and length of hospital stay. This meta-analysis evaluates the impact of postoperative ketamine infusion on pain, opioid use, and recovery outcomes within ERAS protocols for elective open abdominal surgeries. Methods A systematic review and meta-analysis were conducted by screening PubMed, Scopus, and EMBASE up to June 2024. Randomized controlled trials involving adult patients undergoing elective open abdominal surgery were included if they compared postoperative ketamine infusion with standard care or placebo within an ERAS setting. The primary outcomes were postoperative pain intensity, measured using the Visual Analog Scale (VAS), and opioid consumption, converted to morphine equivalents. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and evidence quality was graded using the GRADE approach. A random-effects model was applied to account for heterogeneity across studies. Results Fourteen RCTs involving 1067 patients met inclusion criteria. Ketamine significantly reduced postoperative pain scores (standardized mean difference − 0.53, 95% CI [-0.84, -0.22], p < 0.05) and opioid consumption within the first 24 h post-surgery (standardized mean difference − 0.44, 95% CI [-0.75, -0.13], p < 0.05) compared to control treatments. However, effects on PONV and other adverse events were not statistically significant (Log OR -0.19, 95% CI [-0.81, 0.43], p = 0.55), with considerable heterogeneity across studies (I² = 72.69%). Conclusion Postoperative ketamine infusion within ERAS protocols appears effective in reducing both pain and opioid consumption without significantly impacting PONV or adverse effects. These findings suggest ketamine may be a valuable adjunct in ERAS for elective open abdominal surgeries, though variability in results indicates that optimal dosing and administration strategies require further investigation to maximize patient recovery benefits and minimize side effects.

Introduction Gastrointestinal (GI) endoscopy is a valuable diagnostic tool for identifying upper and lower GI pathologies yet is rarely available in resource-limited settings. This project evaluates the impact of a mobile endoscopy outreach effort implemented across five district hospitals in the Western Cape of South Africa.Methods A mobile endoscopy outreach programme was created and implemented at five district hospitals within the Western Cape of South Africa. Health records of patients who presented for endoscopy across these five hospitals were then retrospectively reviewed. Descriptive statistics were used as part of data analysis.Results A total of 515 procedures (486 oesophagogastroduodenoscopies (94%), 28 colonoscopies (5%) and one proctoscopy (0.2%)) were performed at five district hospitals between January and November of 2024 (323 female (63%), 192 male (37%); mean (SD) age 56 (14) years). The most common pathologies identified across all sites included gastritis (76%), hiatal hernia (70%) and oesophagitis (69%). For all patients, the average distance travelled to their nearest district hospital (Beaufort West, Oudtshoorn, Riversdale, Mossel Bay or Knysna) was 13.6 km (SD (26.6)), compared with the average distance they would have needed to travel to the regional referral centre (mean (SD) 102.1 (66.8) km) in George, South Africa, for the same endoscopy services.Conclusion Implementing a mobile, cost-conscious endoscopy outreach programme can offer diagnostic and therapeutic opportunities to patients in international resource-limited settings, while also alleviating resource strain on regional referral centres. This approach can improve healthcare access and can be replicated in other resource-limited settings.

Objectives To determine the relative efficacy and safety of surgical techniques for parastomal hernia (PH) repair using a Bayesian network meta-analysis (NMA), integrating direct and indirect evidence to generate probabilistic rankings and guide clinical decision-making. Methods We conducted a systematic review and Bayesian NMA of 28 studies (1.983) patients) comparing seven PH repair techniques, following PRISMA-NMA guidelines. The primary outcome was parastomal hernia (PH) recurrence; the secondary outcome was cumulative postoperative complications. Random-effects models with a binomial likelihood and a logit link function were used. SUCRA probabilities ranked interventions; node-splitting assessed inconsistency; meta-regression evaluated covariates. Results FunnelMesh achieved the highest SUCRA score for recurrence reduction (91.55%), significantly outperforming Keyhole (OR 0.06, 95% CrI: 0.01–0.35) and Repair (OR 0.11, 95% CrI: 0.02–0.55). Sandwich ranked second (80%). For complications, Modified Keyhole (KeyholeM) ranked safest (SUCRA = 91%), with a significantly lower complication risk than Sugarbaker (OR = 0.23; 95% CrI: 0.05–0.94) and Keyhole (OR = 0.22; 95% CrI: 0.04–0.92). Node-splitting revealed inconsistencies in the FunnelMesh comparisons, warranting cautious interpretation. Meta-regression confirmed robustness across stoma type, approach, and follow-up duration. Conclusions FunnelMesh and Sandwich offered superior recurrence prevention; KeyholeM provides the optimal balance of low recurrence and minimal complications. The traditional Keyhole technique remained associated with high failure rates, reinforcing current guideline recommendations against its use. These findings provide an evidence-based framework to individualize PH repair strategies based on efficacy and safety trade-offs. Highlights Bayesian network meta-analysis comparing all major techniques for parastomal hernia repair. FunnelMesh, Sandwich, and modified Keyhole achieve the best balance of efficacy and safety. Provides an evidence-based framework to guide surgical selection and patient counseling.

PurposeThis study aimed to construct and compare machine learning models for predicting recurrent extrahepatic bile duct stones after common bile duct explor...