Global 30-Day Morbidity and Mortality of Primary Bariatric Surgery Combined with Another Procedure: The BLEND Study.

BACKGROUND: No robust data are available on the safety of primary bariatric and metabolic surgery (BMS) alone compared to primary BMS combined with other procedures. OBJECTIVES: The objective of this study is to collect a 30-day mortality and morbidity of primary BMS combined with cholecystectomy, ventral hernia repair, or hiatal hernia repair. SETTING: This is as an international, multicenter, prospective, and observational audit of patients undergoing primary BMS combined with one or more additional procedures. METHODS: The audit took place from January 1 to June 30, 2022. A descriptive analysis was conducted. A propensity score matching analysis compared the BLEND study patients with those from the GENEVA cohort to obtain objective evaluation between combined procedures and primary BMS alone. RESULTS: A total of 75 centers submitted data on 1036 patients. Sleeve gastrectomy was the most commonly primary BMS (N = 653, 63%), and hiatal hernia repair was the most commonly concomitant procedure (N = 447, 43.1%). RYGB accounted for the highest percentage (20.6%) of a 30-day morbidity, followed by SG (10.5%). More than one combined procedures had the highest morbidities among all combinations (17.1%). Out of overall 134 complications, 129 (96.2%) were Clavien-Dindo I-III, and 4 were CD V. Patients who underwent a primary bariatric surgery combined with another procedure had a pronounced increase in a 30-day complication rate compared with patients who underwent only BMS (12.7% vs. 7.1%). CONCLUSION: Combining BMS with another procedure increases the risk of complications, but most are minor and require no further treatment. Combined procedures with primary BMS is a viable option to consider in selected patients following multi-disciplinary discussion.

30-day Morbidity and Mortality after Cholecystectomy for Benign Gallbladder Disease (AMBROSE): A Prospective, International Collaborative Cohort Study.

OBJECTIVE: This study aimed to assess 30-day morbidity and mortality rates following cholecystectomy for benign gallbladder disease and identify the factors associated with complications. SUMMARY BACKGROUND DATA: Although cholecystectomy is common for benign gallbladder disease, there is a gap in the knowledge of the current practice and variations on a global level. METHODS: A prospective, international, observational collaborative cohort study of consecutive patients undergoing cholecystectomy for benign gallbladder disease from participating hospitals in 57 countries between January 1 and June 30, 2022, was performed. Univariate and multivariate logistic regression models were used to identify preoperative and operative variables associated with 30-day postoperative outcomes. RESULTS: Data of 21,706 surgical patients from 57 countries were included in the analysis. A total of 10,821 (49.9%), 4,263 (19.7%), and 6,622 (30.5%) cholecystectomies were performed in the elective, emergency, and delayed settings, respectively. Thirty-day postoperative complications were observed in 1,738 patients (8.0%), including mortality in 83 patients (0.4%). Bile leaks (Strasberg grade A) were reported in 278 (1.3%) patients and severe bile duct injuries (Strasberg grades B-E) were reported in 48 (0.2%) patients. Patient age, ASA physical status class, surgical setting, operative approach and Nassar operative difficulty grade were identified as the five predictors demonstrating the highest relative importance in predicting postoperative complications. CONCLUSION: This multinational observational collaborative cohort study presents a comprehensive report of the current practices and outcomes of cholecystectomy for benign gallbladder disease. Ongoing global collaborative evaluations and initiatives are needed to promote quality assurance and improvement in cholecystectomy.

The association between KRAS and histopathological growth patterns and the impact on resection margins around vasculature and bile ducts in colorectal liver metastases.

The liver is the most frequent and often the only site of distant disease in colorectal cancer and, of all treatment protocols currently in use, resection is the most likely to result in long-term cure. Within the liver, tumour proximity to major vasculature and biliary structures poses a resection challenge, requiring a balance of achieving negative margins while preserving adequate vascular circulation and biliary drainage. The focus on parenchymal sparing resections are important but just as important may be the 'biological' behaviour of the tumour. In colorectal liver metastases (CRLM), biomarkers such as the Kirsten rat sarcoma oncogene homologue (KRAS) gene and histological growth patterns (HGPs) further improve the prognostication after resection. However, to date, the association between the KRAS status and HGPs in CRLM and their impact on resection margins around major vasculature or biliary structures in terms of overall survival and recurrence rates are unclear. The aim of this review was to explore the available evidence for the association between KRAS and HGPs in CRLM and attempt to define their impact on resection margins near major structures.

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery.

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs.

Prognostic circulating proteomic biomarkers in colorectal liver metastases.

The liver is the most common site of metastasis in colorectal cancer. Multimodal treatment, including liver resection, is potentially curative and prolongs survival for selected patients with colorectal liver metastases (CRLM). However, the treatment of CRLM remains challenging because recurrence is common, and prognosis varies widely between patients despite curative-intent treatment. Clinicopathological features and tissue-based molecular biomarkers, either alone or in combination, are insufficient for accurate prognostication. As most of the functional information in cells resides in the proteome, circulating proteomic biomarkers may be useful for rationalising the molecular complexities of CRLM and identifying potentially prognostic molecular subtypes. High-throughput proteomics has accelerated a range of applications including protein profiling of liquid biopsies for biomarker discovery. Moreover, these proteomic biomarkers may provide non-invasive prognostic information even before CRLM resection. This review evaluates recently discovered circulating proteomic biomarkers in CRLM. We also highlight some of the challenges and opportunities with translating these discoveries into clinical applications.

Prognostic Models Incorporating RAS Mutation to Predict Survival in Patients with Colorectal Liver Metastases: A Narrative Review.

Recurrence and survival vary widely among patients who undergo curative-intent resection of colorectal liver metastases (CRLM). Prognostic models provide estimated probabilities of these outcomes and allow the effects of multiple potentially interacting variables to be adjusted and assessed simultaneously. Although many prognostic models based on clinicopathologic factors have been developed since the 1990s to predict survival after resection of CRLM, these models vary in their predictive performance when applied to contemporary cohorts. Rat sarcoma viral oncogene homolog (RAS) mutation status is routinely tested in patients with metastatic colorectal cancer to predict response to anti-epidermal growth factor therapy. In addition, mutations in RAS predict survival and recurrence in patients undergoing hepatectomy for CRLM. Several recent prognostic models have incorporated RAS mutation status as a surrogate of tumor biology and combined revised clinicopathologic variables to improve the prediction of recurrence and survival. This narrative review aims to evaluate the differences between contemporary prognostic models incorporating RAS mutation status and their clinical applicability in patients considered for curative-intent resection of CRLM.

Proteomic Profiling and Biomarker Discovery in Colorectal Liver Metastases.

Colorectal liver metastases (CRLM) are the leading cause of death among patients with metastatic colorectal cancer (CRC). As part of multimodal therapy, liver resection is the mainstay of curative-intent treatment for select patients with CRLM. However, effective treatment of CRLM remains challenging as recurrence occurs in most patients after liver resection. Proposed clinicopathologic factors for predicting recurrence are inconsistent and lose prognostic significance over time. The rapid development of next-generation sequencing technologies and decreasing DNA sequencing costs have accelerated the genomic profiling of various cancers. The characterisation of genomic alterations in CRC has significantly improved our understanding of its carcinogenesis. However, the functional context at the protein level has not been established for most of this genomic information. Furthermore, genomic alterations do not always result in predicted changes in the corresponding proteins and cancer phenotype, while post-transcriptional and post-translational regulation may alter synthesised protein levels, affecting phenotypes. More recent advancements in mass spectrometry-based technology enable accurate protein quantitation and comprehensive proteomic profiling of cancers. Several studies have explored proteomic biomarkers for predicting CRLM after oncologic resection of primary CRC and recurrence after curative-intent resection of CRLM. The current review aims to rationalise the proteomic complexity of CRC and explore the potential applications of proteomic biomarkers in CRLM.

Recurrence patterns predict survival after resection of colorectal liver metastases.

BACKGROUND: Effective treatment of colorectal liver metastases (CRLM) is challenging because recurrence occurs in many patients after curative-intent resection. This study evaluates the recurrence patterns after resection of CRLM and its association with survival. METHODS: A retrospective review of prospectively collected data of patients with CRLM managed with curative-intent resection from January 2007 to December 2017 was performed. The main outcomes and measures were the timing of recurrence, initial sites of recurrence, overall survival and recurrence-free survival. Early recurrence was defined as the detection of any organ recurrence ≤6 months from resection of CRLM. RESULTS: A cohort of 194 patients was included for analysis. After a median follow-up of 85.3 months, 145 patients (74.7%) were diagnosed with recurrence. The median overall survival was 67.6 months (95% CI 50.4-80.2) and the 5-year overall survival was 54.1%. After initial recurrence was detected, the median survival was 28.9 months (95% CI 23.6-37.8) months and the 5-year overall survival was 28.8%. Early recurrence occurred in 58 patients (29.9%). Initial recurrence patterns included: liver only in 53 patients (36.5%), multiple sites in 48 patients (33.1%), lung only in 30 patients (20.7%), and other single extrahepatic sites in 14 patients (9.6%). Early recurrence and initial multi-site recurrence were independent predictors of worse overall survival for patients who develop recurrence after resection of CLRM. CONCLUSION: The timing and initial sites of recurrence are prognostic factors in determining survival after curative-intent resection of CRLM.

Performance of prognostic models incorporating KRAS mutation status to predict survival after resection of colorectal liver metastases.

BACKGROUND: The Genetic And Morphologic Evaluation (GAME) score and modified clinical score (m-CS) are two novel prognostic models that incorporate KRAS mutation status to predict survival after resection of colorectal liver metastases (CRLM). This retrospective cohort study evaluated the performance of these two models. METHODS: A total of 103 patients who underwent resection of CRLM between 2007 and 2017 and had known KRAS mutation status were included, 39 (37.9%) of whom had KRAS mutated tumours. Complete case analysis of the patients was performed according to the Clinical Risk Score (CRS), m-CS, and GAME score. The primary outcome was overall survival stratified according to low-risk and high-risk scores. Harrell's C-index and Akaike information criterion (AIC) were used to compare the discrimination of the evaluated prognostic models. RESULTS: The GAME score demonstrated the largest difference in overall survival for patients stratified according to low-risk and high-risk groups. Harrell's C-index values for the CRS, m-CS, and GAME models were 0.583, 0.600, and 0.668, respectively. AIC values for the CRS, m-CS, and GAME models were 441, 439, and 427, respectively. CONCLUSION: The GAME score outperforms the CRS and m-CS in predicting overall survival after resection of CRLM in patients with known KRAS mutation status.

Survival Outcomes for Patients With Indeterminate 18FDG-PET Scan for Extrahepatic Disease Before Liver Resection for Metastatic Colorectal Cancer: A Retrospective Cohort Study Using a Prospectively Maintained Database to Analyze Survival Outcomes for Patients With Indeterminate Extrahepatic Disease on 18FDG-PET Scan Before Liver Resection for Metastatic Colorectal Cancer.

OBJECTIVE: The aim of this study was to evaluate overall survival (OS) and cancer recurrence for patients with indeterminate positron emission tomography (PET) scan for extrahepatic disease (EHD) before liver resection (LR) for colorectal liver metastases (CLMs). SUMMARY OF BACKGROUND DATA: Indeterminate EHD as determined by PET imaging indicates a probability of extrahepatic malignancy and potentially excludes patients from undergoing LR for CLM. METHODS: In a retrospective analysis of prospectively collected data from February 2006 to December 2014, OS for patients with indeterminate EHD on FDG-PET scan before LR for CLM was performed using standard survival analysis methods, including Kaplan-Meier estimator and Cox proportional hazard models for multivariate analyses. Postoperative imaging was used as reference to evaluate the association between indeterminate EHD and recurrence. RESULTS: Of 267 patients with PET scans before LR, 197 patients had no EHD and 70 patients had indeterminate EHD. Median follow-up was 33 months. The estimated 5-year OS was 60.8% versus 59.4% for indeterminate and absent EHD, respectively (P = 0.625). Disease-free survival was comparable between both groups (P = 0.975) and overall recurrence was 57.1% and 59.5% for indeterminate and absent EHD, respectively (P = 0.742). About 16.9% of recurrence was associated with the site of indeterminate EHD, with 80% of associated recurrence occurring in the thorax. CONCLUSIONS: The site of indeterminate EHD appears to have a predictive value for recurrence, with indeterminate EHD in the thorax having a higher probability of malignancy. The evidence in this report supports the critical evaluation of PET scan results and that patients are not denied potential curative LR unless the evidence for unresectable EHD is certain.