ABSTRACT. Background Real-world data on surgical practice patterns and technical quality indicators at a national level for rectal cancer remain scarce. The Breakthrough Improvement Collaborative for Rectal Cancer (BIC4ReCa) was established to document real-world variation and promote evidence-guided quality improvement. Methods A retrospective multicenter cohort study was conducted in 22 Belgian hospitals between 2020 and 2024. Each hospital contributed 20 patients undergoing curative-intent rectal cancer surgery. Results A total of 430 patients were included; 67.9% were male, with a mean age of 68.8 ± 12.0 years. Clinically, 58.6% of tumors were staged cT3 and 56.5% node-positive. Total mesorectal excision (TME) was performed in 347 cases (80.7%), abdominoperineal resection (APR) in 83 (19.3%) (Table 1). Minimally invasive surgery was used in 89.5% (42.3% robotic; range 0–94%). Conversion rates were 8.9% for laparoscopy and 3.1% for robotic surgery. Among TME procedures, splenic flexure mobilization was performed in 66.3% and high ligation of the inferior mesenteric artery in 77.5%. Reconstruction was performed in 92.8%, most commonly end-to-end (68.6%) or side-to-end (23.1%). Anastomoses were predominantly double stapled (71.1%). Anastomotic air leak testing was documented in 76.1%, and indocyanine green angiography in 66.1%. A diverting stoma was constructed in 60.9% of reconstructed TME procedures (interhospital range 25–92%). Median lymph node yield was 13 (IQR 10–19). Mesorectal quality was complete in 80.2%, nearly complete in 5.6%, and incomplete in 0.7%, unreported in 13.5%. Resection margins were described as R0 in 94.7%. Circumferential resection margin (CRM) status was undescribed in 37.0%; among documented cases, 4.4% were CRM positive. Ninety-day mortality was 2.8%. Readmission occurred in 21.1% and reintervention in 19.5%. After reconstructed TME, anastomotic leakage occurred in 17.4%, varying between hospitals (5–32%) (Table 2). Conclusions Substantial national variation exists in surgical approach, technical execution, use of adjunct technologies, and reporting of key quality indicators in rectal cancer surgery.

ABSTRACT. OBJECTIVE Different techniques for ileocecal anastomosis are used in Crohn’s disease (CD), yet comparative data on postoperative and endoscopic outcomes remain limited. This study aimed to compare postoperative complications and endoscopic outcomes between end-to-end (ETE) and side-to-side (STS) anastomoses following ileocecal resection for CD.

METHODS A retrospective cohort study was conducted including all patients scheduled for ileocecal resection for Crohn’s disease between 2006 and 2023. Patients underwent either an isoperistaltic handsewn ETE anastomosis or an isoperistaltic/antiperistaltic handsewn or mechanical STS anastomosis. Data were extracted from electronic medical records and analysed using SPSS v29. Primary endpoint was anastomotic leakage. Secondary endpoints included early postoperative outcomes, late recurrence, endoscopic success, and need for balloon dilatation. Follow-up included clinical visits, laboratory monitoring, and colonoscopy at one year or earlier if indicated.

RESULTS Of 157 scheduled patients, 109 were included with a median follow-up of 147 months. Groups were largely comparable, although the ETE group was younger and more often treated laparoscopically. Length of stay was shorter in the STS group (6 vs. 8 days, p=0.03), while operative time was similar. Anastomotic leakage rates did not differ significantly between STS and ETE (OR 3.16, 95% CI 0.4–23.9; p=0.26), nor did major complications (15% vs. 15%). Ileocolonoscopic failure and balloon dilatation were numerically higher in the STS group but not statistically significant. No differences were observed in recurrence or reoperation rates.

CONCLUSIONS STS and ETE anastomoses demonstrated comparable safety, complication rates, and endoscopic outcomes. Given the advantages of intracorporeal construction and operative efficiency, an intracorporeal isoperistaltic mechanical STS anastomosis is recommended as the preferred technique following ileocecal resection in Crohn’s disease.

ABSTRACT. OBJECTIVE Single-port robotic surgery represents the latest advancement in minimally invasive colorectal surgery, potentially addressing the limitations of single-incision laparoscopy. Evidence for its use in inflammatory bowel disease is limited. This study compared the short-term outcomes of single-port robotic ileal pouch-anal anastomosis (IPAA) surgery for ulcerative colitis (UC) with conventional minimally invasive approaches.

METHODS A retrospective analysis of consecutive UC patients undergoing minimally invasive restorative proctectomy with IPAA after prior total colectomy (February 2024–September 2025) was performed. Patients were grouped by surgical approach (single-port robotic vs. laparoscopic/multi-port robotic). Postoperative outcomes included conversion to open surgery, operative time, 30-day morbidity (Comprehensive Complication Index [CCI]), postoperative pain, C-reactive protein (CRP) levels, length of stay and time to ileostomy closure. Continuous variables were compared using t-test or Mann-Whitney U test and categorical variables by χ² or Fisher’s exact test with p<0.05 considered significant.

RESULTS Thirty-two patients were included, with 16 in each group. Baseline characteristics were similar, except for higher body mass index (BMI) in the single-port group (29 vs. 22 kg/m², p=0.008). The single-port cohort more frequently underwent a three-stage approach and uniformly received a total mesorectal excision with transanal transection and single-stapled anastomosis. No conversions to open surgery occurred. Operative time was significantly longer for single-port surgery (240 vs. 185.5 min, p=0.007). The CCI was comparable (6 vs. 7.5, p=0.342), with all three anastomotic leaks occurring in the control group. Peak CRP levels, pain scores and time to first bowel movement were similar. Length of stay was shorter for single-port patients (5 vs. 9 days, p=0.005), while readmission rates did not differ.

CONCLUSION Single-port robotic restorative proctectomy with IPAA is feasible and safe, even in patients with higher BMI. Despite longer operative times, its low morbidity, absence of anastomotic leaks and shorter hospital stay suggest potential advantages over conventional minimally invasive approaches.

ABSTRACT. OBJECTIVE: Postoperative complications and prolonged recovery remain frequent after colorectal cancer surgery. Preoperative skeletal muscle status may contribute to surgical risk. This study evaluated which preoperative variables, including CT-derived skeletal muscle mass (cross-sectional area) and quality (muscle radiodensity attenuation), predict postoperative outcomes.

METHODS: A retrospective cohort of 604 adults undergoing colorectal cancer resection (2020-2024) was analyzed. Primary outcome was 90-day postoperative complications; secondary outcome was length of hospital stay (≤5 vs ≥6 days). Preoperative CT-scans (L3) quantified erector spinae and iliopsoas muscle cross-sectional area and radiodensity attenuation. Other covariates included preoperative demographic, clinical, laboratory, and tumor-related variables (Table 1). Multivariable logistic regression was used to develop prediction models.

RESULTS: Complications occurred in 53% of patients (21% severe; Clavien-Dindo Classification ≥IIIb) and were associated with WHO performance status (≥2: OR 4.15; 95% CI 2.16–7.94) and lower hemoglobin levels (P=0.035). Muscle parameters were not retained in the complication model. Prolonged hospital stay was associated with WHO performance status (≥2: OR 2.57; 95% CI 1.43–4.62), male sex (OR 1.52; 95% CI 1.04–2.21), BMI (OR 0.28; 95% CI 0.09-0.86), and tumor location (rectum = ref.; sigmoid: OR 0.14, 95% CI: 0.08-0.26; right colon: OR 0.27, 95% CI: 0.17-0.44; colon transversum: OR 0.44, 95% CI: 0.21-0.90). Lower erector spinae muscle radiodensity attenuation was associated with prolonged hospital stay (P<0.001) (Table 1). Model performance showed an AUC of 0.675 for complications and 0.751 for length of stay.

CONCLUSIONS: CT-derived muscle quality provided additional predictive value for length of hospital stay after colorectal cancer surgery. Furthermore, our previous findings demonstrated that patients with declining physical performance had lower CT-based muscle quality, highlighting muscle quality as possible marker of preoperative vulnerability. Complications were primarily driven by WHO status and hemoglobin levels. Incorporating CT-derived muscle quality and physical performance into preoperative assessment may refine risk assessment and support prehabilitation strategies.

ABSTRACT. Objective This study evaluated the functional outcome in women with symptomatic rectocele undergoing ventral mesh rectopexy (VMR). Secondary aims were to identify variables associated with functional results and to assess complications, recurrence and new-onset symptoms. Methods Data were obtained from the prospective Multicenter ventral Mesh Rectopexy Registry (M2R2). The registry collects demographics, preoperative symptoms, operative details, postoperative complications, new-onset symptoms, and recurrence. Functional outcomes (defecatory, urinary and sexual function, symptom improvement) are evaluated using questionnaires from preoperatively to five years postoperatively. Primary analysis focused on one-year change in CRADI-8 score. Paired t-tests or Wilcoxon Signed-Rank tests compaired pre– and postoperative scores; lineair regression explored predictors of CRADI-8 improvement. Results Between October 2023 and January 2026, 129 patients were enrolled across nine centers in Belgium. Rectocele was the primary indication in 89% and obstructed defecation symptoms (ODS) were present in 80% of patients. One-year CRADI-8 data were available for 38 women, with a significant mean CRADI-8 improvement of -13 (95% CI −18.4 to −7.6, p<0.001), indicating less symptoms and bothersome postoperative. Significant gains were also observed in PFDI-20, Wexner-Vaizey, LARS, CRAIQ-7, and PFIQ-7 scores. Patient-reported outcomes were favorable with 84% reporting at least minimal improvement. Complications were rare. Recurrence and new-onset symptoms occured in 1/20 and 8/38 patients respectively. No mesh erosions were identified. Variables associated with CRADI-8 change were mesh type (p=0.027), history of caesarean section (−25.3, 95%CI –48.76 to -1.85, p=0.035), MRI-detected cystocele (14.57, 95%CI 1.58 to 27.56, p=0.029) and preoperative performed anal manometry (−13, 95%CI –23.78 to -2.24, p=0.019). Conclusion In Belgium, VMR is mainly performed for rectocele with ODS. One-year outcomes indicate significant functional improvement and high satisfaction with low recurrence rates. However, voluntary registration and evolving surgical practice may introduce bias. Larger cohorts with extended follow-up are needed to identify reliable predictors of outcome.

ABSTRACT. Background: Preoperative staging is essential in rectal cancer to guide neoadjuvant therapy and surgical planning. Clinical TNM staging relies on pelvic MRI and thoracoabdominal CT. This study evaluated agreement between clinical and pathological TN staging in patients undergoing primary rectal cancer surgery, reflecting real-world practice in a multicenter setting. Methods: A retrospective multicenter cohort study was conducted within the Breakthrough Improvement Collaborative for Rectal Cancer across 22 Belgian hospitals from 2020 to 2024. Patients undergoing curative-intent primary rectal cancer surgery were included. Agreement between clinical and pathological T- and N-stage was assessed using cross-tabulation, simple agreement proportions, and Cohen’s kappa statistics. For T-stage analysis, categories were grouped as T0–2, T3, and T4 due to limitations of MRI in distinguishing T1 from T2 disease. Results: T-stage agreement was analyzed in 178 patients. Exact agreement between cT and pT occurred in 71.3%, with partial agreement in 28.7%. Pathological upstaging occurred in 12.4% and downstaging in 16.3%. Agreement was highest for early-stage tumors (pT0–2: 74.8%), lowest for pT4 disease (50.0%). Overall concordance for T stage was moderate (Cohen’s kappa 0.42; weighted kappa 0.45; p<0.001). Nodal staging agreement was assessed in 181 patients. Exact agreement between cN and pN was observed in 63.5%, partial agreement in 29.3%. Pathological nodal upstaging occurred in 19.9% , downstaging in 16.6%. Agreement was highest for node-negative disease (pN0: 78.1%) and lower for node-positive stages (pN1: 33.3%; pN2: 9.1%). Overall nodal agreement was poor (Cohen’s kappa 0.16; weighted kappa 0.16; p<0.01). Conclusions: Clinical T staging agreed with pathology in 71.3%, with both over- and understaging observed. Agreement for nodal staging was substantially lower at 63.5%, with frequent pathological understaging. These findings demonstrate limitations of imaging-based TN staging in rectal cancer and support improved standardized risk-based staging incorporating additional high-risk features such as EMVI, tumor deposits, and MRF involvement.

ABSTRACT. Objective Construction of an ileostomy is a common procedure in patients undergoing a colorectal resection and can be associated with high output ileostomy (HOS). The aim of this study was to evaluate the effectiveness of a multimodal education and follow-up protocol to reduce HOS and to prevent readmission. Methods A retrospective interventional cohort study of all patients having an ileostomy fashioned between January 2018 and September 2023. Patients in the pretest group received a preoperative consultation with the surgeon, the ostomy team and standard postoperative nutritional advice. Patients in the post test group were in addition informed according to the multimodal educational protocol with follow-up at discharge through a diary, and telephone consultations with a nurse specialist. The primary outcome was a 90-day readmission rate due to HOS. Secondary outcomes were 30-day readmission rate, length of stay and postoperative complications. Results A total of 799 patients were included of whom 367 in the pre-intervention group and 432 patients in the post-intervention group. Median age was 54 years (range 16-88), 52% were male, median BMI of 24 kg/m² and most patients had ASA class II (54.2%). The primary surgical indications were inflammatory bowel disease (41.1%) and colorectal cancer (38.2%). Laparoscopy was used in 64% of cases. Overall, the 90-day readmission rate for HOS decreased from 18% to 4.2% (P < 0.001). In colon surgery and rectal surgery the reduction was 16.9% to 4% (P < 0.001) and 20% to 4.6% (P < 0.001), respectively. Conclusion The findings of this study underscore the potential of a multimodal educational protocol to reduce readmissions in patients undergoing colorectal surgery with ileostomy creation.

ABSTRACT. Objective: As population aging accelerates, colorectal surgeons increasingly operate on octogenarians and nonagenarians, a group traditionally perceived as very high risk. This narrative overview summarizes contemporary evidence on perioperative risk stratification, optimization strategies, and outcomes in very elderly patients undergoing colorectal surgery, with emphasis on frailty, postoperative complications, procedure-specific risk, and prehabilitation.

Methods: A narrative review of clinical practice guidelines, randomized, and observational studies, cohort analyses, emulated target trials, and systematic reviews was conducted focusing on patients aged ≥80 years. Outcomes of interest included perioperative morbidity and mortality, predictors of adverse events, frailty assessment, geriatric co-management, prehabilitation, perioperative optimization, and surgical factors influencing outcomes.

Results: Chronological age, even at advanced extremes, is not an independent contraindication to colorectal surgery. Frailty, comorbidity burden, functional impairment, malnutrition, and diminished physiological reserve are the principal determinants of postoperative morbidity and mortality in octogenarians and nonagenarians. Very elderly patients experience high rates of medical complications-particularly pulmonary events, postoperative delirium, and infections-which substantially contribute to early mortality and failure-to-rescue. Procedure-specific factors, especially anastomotic leakage and surgical complexity, exert a disproportionate impact on mortality. Importantly, growing evidence indicates that frailty and physiological reserve are modifiable: structured prehabilitation programs combining physical, nutritional, and geriatric interventions are associated with reduced complications and improved short- and medium-term outcomes, even in frail patients aged ≥80 years. Contemporary literature also supports acceptable surgical and oncological outcomes in carefully optimized patients managed within multidisciplinary and Enhanced Recovery After Surgery (ERAS) pathways.

Conclusions: Colorectal surgery in octogenarians and nonagenarians is feasible but highly dependent on physiological reserve rather than chronological age. Outcomes are driven by medical complications and procedure-specific risk; however, targeted prehabilitation and comprehensive geriatric optimization can meaningfully modify this risk. Integration of frailty-based assessment, prehabilitation, and multidisciplinary perioperative care should replace age-based exclusion in contemporary colorectal surgical practice.

ABSTRACT. Background Despite advances in colorectal surgery, postoperative complications remain frequent and continue to affect patient outcomes and experience. Enhanced Recovery After Surgery (ERAS) programs have been widely implemented to optimize perioperative care and accelerate recovery. However, variability in outcomes persists, particularly among older patients, and real-world adherence to ERAS elements is inconsistent. Methods This retrospective multicenter cohort study used data from a Quality Improvement Collaborative in Flanders, including adult patients undergoing elective colectomy for non-metastatic colon cancer (2017-2023). Patients were stratified by age (≤75 vs. >75 years). ERAS adherence was assessed using compliance with 12 core ERAS components. Primary outcomes were postoperative morbidity and length of stay, with secondary analyses assessing age-related differences. Linear mixed-effects models adjusted for confounders and hospital-level clustering. Results A total of 1,617 patients were included, of whom 645 were older than 75 years. Overall ERAS adherence was comparable between age groups. Older patients (>75 years) more frequently had prolonged urinary catheter use and were less likely to achieve early postoperative mobilization. Postoperative complication and 30-day readmission rates did not differ significantly between groups. However, older patients experienced a longer median hospital stay (6.3 vs. 5.2 days). Figure 1 illustrates adherence rates to individual ERAS components across age categories. The lowest adherence rates were observed for early mobilization (defined as walking ≥5 meters), carbohydrate loading, and opioid-free pain management. In contrast, antibiotic prophylaxis, minimally invasive surgery, and avoidance of sedative medication showed the highest adherence across all age groups. Early mobilization and avoidance or early removal of urinary catheters demonstrated the most pronounced decline with increasing age. Conclusion Most ERAS components are feasible in older patients undergoing elective colon cancer surgery, with similar morbidity and readmission rates. Targeted improvement of early mobilization and catheter management may further shorten hospital stay and enhance recovery in this population.

ABSTRACT. Objectives: Mycotic aneurysms of the femoral artery are rare but potentially fatal vascular complications that usually result from hematogenous bacterial seeding of the arterial wall during episodes of bacteremia. Salmonella species represent an uncommon but well documented etiology, predominantly affecting elderly or immunocompromised patients. The objective of this report is to describe a rare case of Salmonella associated mycotic aneurysm of the common femoral artery and to emphasize the importance of early diagnosis and timely multidisciplinary management. Methods: We present the case of an 80 year old male admitted with gastrointestinal symptoms who was diagnosed with Salmonella spp bacteremia. During hospitalization, the patient developed progressive left inguinal pain without fever, local inflammatory signs, or a palpable pulsatile mass. A thorough clinical evaluation was followed by contrast enhanced computed tomography to investigate a suspected vascular complication. Results: Imaging revealed a saccular aneurysm of the left common femoral artery consistent with a mycotic aneurysm. Given the high risk of rupture and systemic infection, urgent surgical treatment was performed. The procedure included complete resection of the infected aneurysm and arterial reconstruction with a left iliofemoral bypass using a reversed great saphenous vein graft. Targeted intravenous antibiotic therapy was administered postoperatively. The patient experienced an uneventful recovery with resolution of symptoms and no early postoperative complications. Conclusion: This case underscores the need for a high index of suspicion for vascular complications in patients with Salmonella bacteremia presenting with localized pain. Early imaging, aggressive surgical debridement, and revascularization using autologous vein grafts combined with appropriate antimicrobial therapy are essential for optimal outcomes. Prompt recognition and coordinated multidisciplinary care are critical to reducing morbidity and mortality associated with this rare but life threatening vascular infection in elderly patients with multiple comorbidities and increased susceptibility to systemic infections.

ABSTRACT. OBJECTIVE Recurrent hiatal hernia (HH) after surgical correction remains a clinical challenge, even after revision surgery. Reinforcement of the posterior hiatus with synthetic mesh has shown limited effectiveness to date. Previous studies show that recurrences mainly develop at the left anterior side of the hiatus. Circular hiatal reinforcement may reduce the risk of recurrence. Since circular synthetic mesh reinforcement carries a high risk of serious complications, this study evaluates the use of circular bio-absorbable mesh in revision surgery for recurrent HH. METHODS A retrospective cohort study was conducted using prospectively collected data from revision procedures for recurrent hiatal hernia. Two groups were compared: patients who underwent conventional revision surgery and patients who underwent revision surgery with additional circular bio-absorbable mesh reinforcement. The primary outcome was radiologically confirmed recurrence ≥ 2 cm on CT scan or swallow X-ray at ≥ one year. Secondary outcomes included patient-reported symptom and satisfaction scores, collected via questionnaires. RESULTS 92 patients were included: 38 with conventional revision surgery and 54 with additional circular bio-absorbable mesh reinforcement. Unadjusted recurrence rates were lower in the mesh group (44.7% vs. 22.2%; p = 0.022). However, there was a clinically relevant difference in follow-up duration, which was longer in the conventional revision group. In a Cox proportional hazards analysis, circular bio-absorbable mesh reinforcement was not associated with a significant reduction in the risk of recurrence over time (HR = 0.785; 95% CI 0.353–1.747; p = 0.553). Patient-reported quality of life was higher in the mesh group at one year and two years postoperatively. No differences were found in complication rates or total length of stay. CONCLUSIONS Circular bio-absorbable mesh reinforcement appears safe in recurrent hiatal hernia correction and demonstrates improved short-term quality of life, but no significant reduction in risk of recurrence over time.

ABSTRACT. OBJECTIVE The introduction of immune checkpoint inhibitors has markedly improved outcomes in patients with cutaneous melanoma.But this treatment is associated with a wide spectrum of immune-related adverse events. Splenic complications are rare and poorly documented. We present an unusual case of functional autosplenectomy that occurred after diffuse splenic hypermetabolism in a patient treated with nivolumab.

METHODS We present the clinical case of a 30-year-old woman who received adjuvant nivolumab following complete surgical resection of stage III cutaneous melanoma. Clinical data were correlated with biological findings and sequential imaging, including fluorodeoxyglucose positron emission tomography with computed tomography, magnetic resonance imaging, as well as technetium-99m–labeled red blood cell scintigraphy. A comprehensive workup excluded infectious, autoimmune, hematologic, vascular, and malignant causes of splenic dysfunction.

RESULTS Nineteen months after initiation of nivolumab treatment, fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography revealed diffuse and homogeneous splenic hypermetabolism, with higher uptake in the spleen than in the liver, and no evidence of melanoma recurrence. Subsequent magnetic resonance imaging revealed diffuse splenic signal abnormalities with microcalcifications, while scintigraphy confirmed complete asplenia. Peripheral blood smear also showed Howell–Jolly bodies. Due to persistent abdominal pain and concern for malignant transformation, laparoscopic splenectomy was performed. Histological examination revealed numerous Gamna–Gandy bodies, without any signs of malignancy, portal hypertension or hemoglobinopathy.

CONCLUSIONS This case describes a previously unrecognised sequence linking immune-mediated splenic hypermetabolism to functional autosplenectomy following immunotherapy. This case report might broaden the spectrum of splenic immune-related adverse events and may support the hypothesis that immune checkpoint inhibition could induce microvascular alterations leading to irreversible splenic damage. Awareness of this potential complication is important for long-term follow-up of patients treated with immune checkpoint inhibitors.

ABSTRACT. OBJECTIVE Reconstruction of full-thickness nasal ala defects remains surgically challenging due to the need to restore the internal lining, provide adequate structural support, and achieve satisfactory external skin coverage. Preservation of nasal function and aesthetic appearance is essential. This report describes a combined reconstructive technique and evaluates its functional and aesthetic outcomes.

METHODS A 76-year-old female patient with an extensive basal cell carcinoma of the nose underwent full-thickness excision of the nasal ala. Nasal reconstruction was performed in a staged approach. The internal nasal lining was reconstructed using an epithelial turn-in flap derived from a nasolabial flap. The flap was deepithelialized at the pedicle, turned inward, and suspended to the columella to maintain nasal patency and preserve the contour of the alar rim. The donor site was closed primarily, extending the nasolabial fold. External skin coverage was achieved using a paramedian forehead flap based on the supratrochlear artery, rotated 180 degrees and left pediculated for four weeks. In a second stage, the pedicle was divided to refine the aesthetic result. Postoperative assessment included clinical evaluation, patient-reported aesthetic satisfaction, and objective nasal airflow measurements.

RESULTS The postoperative course was uneventful, with no major complications observed. Nasal airflow measurements demonstrated values within the normal physiological range, indicating adequate nasal patency. Clinical evaluation showed good nasal contour, symmetry, and skin color match. The patient reported satisfaction with the aesthetic outcome.

CONCLUSIONS This case demonstrates that reconstruction of full-thickness nasal ala defects using an epithelial turn-in nasolabial flap for internal lining combined with a paramedian forehead flap for external coverage can result in satisfactory functional and aesthetic outcomes. This technique represents a reliable option for complex nasal ala reconstruction. Further studies with larger patient cohorts are required to validate these findings.

ABSTRACT. OBJECTIVE: To describe the surgical management and early outcome of a complex abdominal aortic aneurysm associated with extensive visceral and aorto-iliac occlusive disease, responsible for digestive claudication and lower limb ischemia, treated by open aortobifemoral bypass with celiac territory revascularization via the splenic artery and splenectomy.

METHODS: A 64-year-old man presented with chronic digestive claudication and right lower limb claudication. He had a history of superior mesenteric artery bypass. An angio-CT revealed a thoraco-abdominal aortic ectasia/aneurysm (CRAWFORD TYPE III), occlusion of the celiac trunk and inferior mesenteric artery, and an aneurysm of the mesenteric bypass, which was thrombosed, with collateralization through the left hypogastric artery. There was also severe aorto-iliac occlusive disease, including bilateral external iliac artery occlusion with extensive pelvic and gluteal collateral circulation supplying the common femoral arteries (Figure1).

During the procedure, it was impossible to approach the suprarenal aorta without damaging collaterals arising from the hypogastric network. In this context, it was decided to perform a subrenal aorto-bifemoral bypass with a side-to-side anastomosis on the aortic bifurcation, then an end-to-side anastomosis on the common femoral arteries. Finally, a splenectomy was performed to use the splenic artery, which was connected to the prosthesis via a great saphenous vein graft.

RESULTS: The surgical procedure was completed successfully without intraoperative complications. Postoperatively, digestive claudication resolved completely, and lower limb perfusion improved with disappearance of ischemic symptoms. No early visceral ischemia, graft thrombosis, or major postoperative complications occurred. Follow-up imaging confirmed patency of the aortobifemoral bypass and adequate visceral perfusion, with graft patency.

CONCLUSION: In patients with complex abdominal aortic aneurysms associated with extensive visceral and aorto-iliac occlusive disease, open aortobifemoral bypass combined with alternative visceral revascularization strategies, such as splenic artery inflow, is feasible and effective. This approach allows simultaneous treatment of digestive and lower limb ischemia when standard or endovascular options are limited.

ABSTRACT. OBJECTIVE The adoption of robotic systems for coronary surgery has been limited compared to other specialties. This study evaluates the implementation, early clinical results, and learning curve associated with robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) in a moderate volume center. METHODS A retrospective analysis was conducted on all consecutive patients who underwent RA-MIDCAB (robotic left internal mammary artery harvest with anastomosis via mini-thoracotomy) between February 2022 and July 2025. Primary endpoints were perioperative outcomes, complications, and 30-day mortality. Operative times were analyzed sequentially to define the procedural learning curve. RESULTS Sixty-seven patients were included. Median age was 64 years. Conversion to sternotomy occurred in 3 cases (4.5%). The median operative time was 225 minutes (range 165–360), demonstrating a significant learning curve. The initial 20 cases had a median time exceeding 260 minutes, while the last 20 cases were consistently under 200 minutes. There was no 30-day mortality or stroke. Complications included one perioperative myocardial infarction (1.5%), one new atrial fibrillation (1.5%), and one re-exploration for bleeding (1.5%). The median hospital and intensive care unit stays were 7 and 2 days, respectively. During follow-up, 3 patients (4.5%) required repeat revascularization. CONCLUSIONS RA-MIDCAB was successfully implemented with excellent early safety outcomes. Operative times decreased significantly after approximately 20 cases, indicating a clear learning curve. While short hospital stays, and low complication rates confirm safety. RA-MIDCAB emerges as a reliable minimally invasive option for LAD revascularization, opening perspectives for future multivessel applications.

ABSTRACT. Background: In esophageal cancer surgery one of the most severe complications is an anastomotic leak. Endoscopic vacuum therapy exist now for a few years and has changed the way of treating anastomotic leaks. This study focuses on the use of the endoscopic vacuum therapy after Ivor-Lewis esophagectomy: morbidity, mortality, length of stay and modalities of use. Methods: All patients that underwent an Ivor Lewis procedure for esophageal cancer and needed an endoscopic vacuum therapy postoperatively, were selected since the first introduction of the endoscopic vacuum therapy in the hospital in 03/2019 until 12/2024. Results: In this time frame, 449 patients were operated for esophageal malignancies. 46 patients needed endoscopic vacuum therapy. The mean time between operation and development of an anastomotic leak was 8.1 days (range between 1-20 days). The mean number of changes of the endoscopic vacuum system was 2.7 (range 1 – 6). 27 patients (58.7%) received a stent after endoscopic vacuum therapy. The 30-day mortality in this group was 2.2% (1/46). ). The 90-day mortality was 10.9% (5/46). Conclusions: Endoscopic vacuum therapy to treat anastomotic leakage in patients after Ivor Lewis esophagectomy has promising results. In this subgroup of patients, a low mortality is seen.

ABSTRACT. Background: Periodontal Ehlers-Danlos syndrome (pEDS) (OMIM#130080) is a rare autosomal dominant subtype of Ehlers-Danlos syndrome characterized by early-onset periodontitis and pretibial hyperpigmentation. Major manifestations include severe gingival recession, lack of attached gingiva, easy bruising, and skin fragility. Vascular complications are less frequent than in vascular EDS but may occur. Early diagnosis is essential for appropriate management and family risk assessment. Case presentation: A 41-year-old man presented with bilateral leg swelling, recurrent venous ulcers, and impaired wound healing. Examination revealed pretibial hyperpigmentation, progeroid appearance, dental prosthesis, thin skin, and dermatitis. His 5-year-old daughter showed similar hyperpigmentation. Genetic testing identified a pathogenic C1R variant (c.1073G>A, p.(Cys358Tyr)) in both, confirming pEDS. Conclusion: pEDS patients may seek treatment in vascular or haematology departments, particularly when symptoms such as easy bruising, bleeding tendencies, or vascular complications are significant. Recognizing key symptoms, such as periodontitis and pretibial hyperpigmentation, is vital for genetic referral and comprehensive care.

ABSTRACT. Background Multivisceral transplantation (MVTx; liver/stomach/pancreas/intestine) is a life-saving procedure in patients suffering from complex diffuse abdominal diseases. In this surgically challenging procedure, a single cluster of organs is implanted on a combined arterial patch including celiac trunk (CT) and superior mesenteric artery (SMA). Arterial inflow into the bloc is usually via a donor-derived aortic conduit anastomosed to the recipient aorta. We aim to analyze the technical variations of the aortic conduit and its complications. Methods An international survey was conducted (12/2024-12/2025) to evaluate center specific aortic conduit protocol and complications. Of 51 intestinal transplantation centers contacted, 6 centers (12%) reported 280 MVTx, of which 78.5% were from a single institution. Results 243 (87%) were “standard” MVTx, 37 (13%) were modified MVTx (mMVTx, stomach/pancreas/intestine). The aortic conduit was constructed of donor abdominal aorta containing CT and SMA (8%), of donor iliac artery (1%), or donor thoracic aorta either anastomosed to (1) a patch containing CT and SMA (6%) (2) abdominal aorta containing CT and SMA (7%) or (3) abdominal aorta containing CT and SMA extended by a second part of thoracic aorta (79%). Position on recipient aorta was infrarenal in all but one patient (orthotopic position). Aortic conduit complications (n=14, 5%) (and related deaths n=7, 2.5%) were stenosis/kinking of the SMA ostia 3/1 of 280, respectively (0 death), mycotic aneurysm 5/280 (3 deaths), thrombosis 1/280 (1 death), aorto-enteric fistula 2/280 (2 deaths) and bleeding 2/280 (1 death). 1-/5-/10-yr patient survival: 67%/51%/39%. Conclusion Several technical variations on aortic conduit in (m)MVTx are used worldwide. Internationally there exists no standardized protocol, however, related complications cannot be specifically linked to one technique. Although limited, complications of the aortic conduit carry a high mortality rate of 50%.

ABSTRACT. OBJECTIVE : Communicating bronchopulmonary foregut malformations are exceptionally rare congenital anomalies and remain a diagnostic challenge, owing to their complex bronchial and vascular anatomy. We report a neonatal case of a type III communicating bronchopulmonary foregut malformation involving the right lower lobe and discuss diagnostic pitfalls and surgical management. METHODS : A male neonate with antenatal suspicion of sliding hernia hiatal and congenital lobar overinflation was transferred to a tertiary referral center after postnatal respiratory deterioration. Postnatal computed tomography angiography demonstrated a hypoplastic right lower lobe supplied by a large aberrant systemic artery arising from the celiac trunk, with preserved pulmonary venous drainage. An abnormal bronchial tree originating from the distal intrathoracic esophagus and supplying the right lower lobe was identified. Flexible bronchoscopy showed a normal trachea and proximal bronchial anatomy without evidence of tracheoesophageal fistula. Based on computed tomography angiography, a diagnosis of type III communicating bronchopulmonary foregut malformation was established. Surgical treatment consisted of right lower lobectomy through posterolateral thoracotomy with division and closure of the esophageal bronchial communication. RESULTS : Surgery was performed on day six of life. Intraoperative findings confirmed an esophageal bronchus supplying the right lower lobe with mixed systemic and pulmonary arterial supply. Postoperative respiratory recovery was progressive, allowing successful weaning from ventilatory support. The postoperative course was complicated by severe esophageal dysmotility and significant gastroesophageal reflux, requiring prolonged enteral nutritional support and multidisciplinary management. At short-term follow-up, the patient demonstrated stable respiratory status and appropriate weight gain. CONCLUSIONS: Communicating bronchopulmonary foregut malformations should be considered in neonates presenting with atypical pulmonary anatomy and associated esophageal abnormalities. Detailed multimodal imaging is essential for accurate diagnosis and surgical planning. Early surgical resection is feasible and effective; however, associated foregut functional disorders may significantly influence postoperative management and justify close multidisciplinary follow-up.

ABSTRACT. Objective Congenital extrahepatic portosystemic shunts (CEPS), also known as Abernethy malformations, are rare vascular anomalies that may present with nonspecific gastrointestinal or hematologic symptoms. We report a case of an 18-year-old woman with obscure gastrointestinal bleeding and severe iron deficiency anemia in whom an Abernethy malformation was diagnosed, highlighting the surgical–vascular relevance of this entity. Methods The patient initially presented with mesogastric pain, melena, and severe iron deficiency anemia (Hb 7.3 g/dL). Endoscopy showed H.pylori infection and eosinophilic esophagitis; colonoscopy, Meckel-scan, and enterography excluded lower gastrointestinal bleeding and inflammatory bowel disease. She required intravenous iron therapy. Later on abdominal CT performed for lower abdominal pain and fever incidentally demonstrated a congenital portosystemic shunt with direct communication between the portal venous system and the inferior vena cava (VCI), associated with dilated portal, splenic, and superior mesenteric veins. Due to the findings of a malformation, she was referred by the general practitioner to the vascular surgeon. The connection with her anemia was only made at this point. Clinical data, endoscopic findings, laboratory results, and cross-sectional imaging were reviewed. Results Imaging findings were consistent with an Abernethy malformation. These malformations are classified into type I (end-to-side shunting of portal vein into VCI; Ia: splenic and superior mesenteric vein drain separately, type Ib: both veins drain together after forming common trunck) and type II (side-to-side shunt with hypoplastic but present intrahepatic portal veins). The malformation provides a plausible vascular explanation for gastrointestinal bleeding and chronic iron deficiency anemia through portal hypertension–related mucosal changes and ectopic variceal formation. Conclusion Abernethy malformations should be considered in young patients with unexplained gastrointestinal bleeding and severe anemia after negative standard work-up. Vascular imaging is essential for diagnosis and classification, which directly guides management, including surveillance, endovascular occlusion, or surgical correction in selected cases.

ABSTRACT. OBJECTIVE: To assess whether natural orifice specimen extraction improves postoperative recovery compared with conventional mini-laparotomy extraction in elective robotic anterior resection for benign sigmoid pathology. METHODS: A retrospective single-center study included consecutive patients undergoing elective robotic anterior resection (Da Vinci Xi) performed by a single surgeon between October 2021 and October 2025. Patients were divided into natural orifice specimen extraction (NOSE) and conventional extraction through a right iliac fossa incision. The primary endpoint was length of stay. Secondary outcomes included operative time, postoperative C-reactive protein on day 1, mean postoperative pain score on day 1, Clavien–Dindo graded complications, anastomotic leak, 30-day reoperation and readmission. Multivariable regression analyses adjusted for age and body mass index were performed. RESULTS: A total of 123 patients were included, of whom 52 underwent NOSE. Baseline characteristics, including age, body mass index, and surgical indication, were comparable between groups. Length of stay was significantly reduced in the NOSE group (median 2 [IQR 1–3] vs 2 [IQR 2–3] days; p=0.002), indicating a shift to earlier discharge despite identical medians. Operative time was shorter with NOSE (115.8±26.7 vs 144.7±43.6 minutes; p<0.001). In multivariable regression adjusting for age and body mass index, NOSE remained independently associated with shorter hospitalization (p=0.024). Postoperative inflammatory response and pain were similar (C-reactive protein day 1: 45.7±32.3 vs 49.6±38.4 mg/L, p=0.65; mean pain score day 1: 1.52±1.19 vs 1.64±1.51, p=0.29). Major complications were rare (3.8% vs 5.6%, p=0.68). Anastomotic leak occurred in one patient per group. Thirty-day reoperation (3.8% vs 5.6%, p=0.65) and readmission rates (3.8% vs 8.5%, p=0.31) did not differ significantly. CONCLUSIONS: In elective robotic anterior resection for benign disease, NOSE was associated with shorter operative time and earlier discharge without increased morbidity, anastomotic leak, reoperation, or readmission. These findings support NOSE as a safe minimally invasive extraction strategy in selected patients.

ABSTRACT. Objectives Complex pancreatic surgery with curative intent remains invasive and is associated with a high risk of perioperative morbidity. The development of new minimally invasive techniques, centralization of care and improvement of adjuvant treatment has further reduced postoperative morbidity and mortality. Recent literature has focused increasingly on health-related quality of life after pancreatectomy. This retrospective study aimed to analyze the evolution of well-being after pancreatic surgery, identifying possible factors influencing the patients’ perceived wellbeing. Methods All patients who underwent surgical pancreatectomy, at a single center, between January 2021 and December 2024 were included. A retrospective study of the medical records was performed to retrieve patient characteristics, perioperative data and postoperative results. Patient wellbeing was assessed at fixed intervals after the procedure, according to a ten-point scale. Results 240 patients have been included in our non-randomized case series. We found that a high preoperative SF-36 score assessment was significantly related to higher postoperative patient reported wellbeing scores starting 3 months after surgery (p = 0,004). Whether the patient was referred from another hospital for surgery had no influence on postoperative wellbeing. Undergoing a surgical reintervention or readmission in the perioperative period had an impact on short-term well-being (p < 0,001) but had no impact on well-being after one year (p = 0,269). A minimally invasive approach was significantly associated with higher wellbeing at 3 months (p = 0,011). High Clavien-Dindo score was associated with significantly lower wellbeing scores after one month (p = 0,004) and one year (p = 0,027). Conclusions Our preliminary findings suggest that patient-reported outcomes are relevant metrics during the postoperative course. A total of 270 patients will be included. Further analysis will be performed in March after all patients have completed 1 year of postoperative follow-up. Our complete findings will be reported during a presentation at the Belgian Surgical Week.

ABSTRACT. OBJECTIVE:

Descending necrotizing mediastinitis is a rare but devastating infection with persistently high mortality despite advances in imaging, antibiotics, and critical care. Esophageal perforation as a secondary complication of descending necrotizing mediastinitis is exceptionally rare and represents the convergence of two life-threatening conditions. Optimal management in this setting remains ill defined. We present a rare case of esophageal perforation secondary to descending necrotizing mediastinitis and emphasize an aggressive, organ-preserving surgical strategy.

METHODS:

A 71-year-old woman initially treated for an oropharyngeal infection deteriorated clinically and was diagnosed with descending necrotizing mediastinitis complicated by proximal esophageal perforation on contrast-enhanced computed tomography and upper endoscopy. Surgical exploration revealed extensive posterior mediastinal necrosis and a transmural proximal esophageal defect measuring up to 4 cm (A). Following mediastinal drainage, endoscopic vacuum therapy (EVT) was initiated and exchanged at regular intervals. After achieving adequate cavity control and granulation, a fully covered esophageal stent was placed (B). Subsequent endoscopic reassessment demonstrated progressive defect closure and complete mucosal healing (C).

RESULTS:

In this case, EVT avoided emergent esophagectomy and resulted in complete recovery without dysphagia or recurrent infection at mid-term follow-up. EVT provided active drainage, effective source control, and progressive granulation of the esophageal defect, resulting in rapid clinical stabilization and reduction of inflammatory markers. This modality represents a decisive, organ-preserving option for esophageal perforations with mediastinal contamination or necrosis, clinical scenarios in which stent therapy alone is frequently inadequate.

CONCLUSIONS:

Esophageal perforation should be recognized as a rare but lethal complication of descending necrotizing mediastinitis. Early diagnosis, radical mediastinal drainage, and the use of endoscopic vacuum therapy can offer effective infection control and esophageal preservation. This case supports endoscopic vacuum therapy as a decisive, organ-sparing alternative to high-risk surgical resection in selected patients.

ABSTRACT. OBJECTIVE Being one of the most common performed procedures by a general surgeon, laparoscopic cholecystectomy (LC) is carried out daily in most surgical centers worldwide. Performing a routine intraoperative cholangiography (IOC) for visualization of the common bile duct (CBD), detection of CBD stones, and intraoperative bile duct injury (BDI) remains a much-debated topic.

METHODS A retrospective observational single-center study was performed at a teaching hospital in Belgium. All adult patients who underwent a laparoscopic cholecystectomy from January 2016 to April 2021 were included and received routine IOC according to a standardized protocol. Operative time, conversion rate, 30-day postoperative complications, readmissions, and length of stay (LOS) were analyzed. Cholangiography anomalies were registered, and results of the adjuvant endoscopic retrograde cholangiopancreatography (ERCP) were reported.

RESULTS A total of 1878 patients were enrolled in the study. A total of 4.9% complications were registered, mostly Clavien-Dindo grade 1 or 3, with 2 bile duct injuries (BDI) in the whole study population. LOS was 3.1 days on average. There were 0.91% readmissions. Common bile duct stones were detected in 6.5% of the patients during cholangiography, and this led to a same admission ERCP in 75.4%.

CONCLUSIONS Routine IOC during LC can be performed with low complication rates and possibly decreasing LOS and readmission rate. In surgical training, it may enhance understanding of bile duct anatomy, improve technical skills, and contribute to a more standardized and safer laparoscopic cholecystectomy.

ABSTRACT. Objectives: To compare the efficacy and safety of ultrasound (US)-guided versus computed tomography (CT)-guided stereotactic percutaneous thermal ablation (PTA) in patients with hepatocellular carcinoma (HCC), with a focus on incomplete ablation, early local recurrence, and 12-month local tumor progression-free survival (LTPFS).

Materials and methods: We conducted a retrospective cohort study comparing US-guided freehand and CT-guided stereotactic PTA in patients with imaging-confirmed HCC. Patients treated with US-guided PTA (n =33) at Erasme Hospital between 2005 and 2022 were compared to those treated with CT-guided stereotactic PTA (n = 52) at Antwerp University Hospital between 2020 and 2023. The primary endpoints were incomplete ablation and early local recurrence. Secondary endpoints included postoperative complications, hospital stay, and 12-month LTPFS. Lesion-based outcomes were also analyzed, including stratification by anatomical location and depth.

Results: Incomplete ablation was significantly less frequent in the CT-guided group on a per-lesion basis (4.7 % vs. 20.5 %, p =0.007). Early local recurrence per lesion was also lower with CT guidance (8.5 % vs. 22.6 %, p = 0.038). In anatomically challenging segments (II, IVa, VII, VIII), CT-guided stereotactic PTA demonstrated a pronounced advantage, with significantly fewer incomplete ablations (7.5 % vs. 30.4 %, p =0.015). Complication rates and median hospital stay (1 day) were similar between groups. CT-guided PTA was further associated with significantly improved 12-month LTPFS (p =0.004).

Conclusion: CT-guided stereotactic PTA resulted in superior local control and 12-month progression-free survival compared to US-guided PTA, particularly in anatomically challenging lesions. These findings support the use of stereotactic CT guidance for improved ablation outcomes in HCC.

ABSTRACT. Introduction

Peritoneal metastases have a dismal prognosis. Laparoscopic aerosolized intraperitoneal chemotherapy (PIPAC) may improve outcomes and palliate symptoms.

Objectives

To report tolerability, toxicity, and treatment response in patients treated with PIPAC for peritoneal metastases from gastrointestinal cancer.

Methods

Data were collected from patients treated with PIPAC (September 2015 - November 2025). Variables included demographics, number of PIPACs, treatment response (radiology, peritoneal cancer index, tumour markers, histopathology of peritoneal samples), and postoperative complications graded with the Clavien-Dindo classification. Overall survival was analysed from time of PM diagnosis.

Results

In total, 261 patients (M: 51.3%) with a mean age of 59.7 years underwent 730 PIPACs and a median of three PIPACs (range 1-16). Most patients (63.6%) received concurrent systemic chemotherapy and had a gastric (25.7%), colorectal (21.5%) or pancreatic adenocarcinoma (13.8%). Postoperative complications occurred in 22.1% of patients, mostly grade I-II (87.5%), five grade III, and two grade IV events. Postoperative abdominal pain was the most common complication. Radiological assessment in 129 patients showed stable disease, regression, or progressive PM in 62%, 7.8%, and 30.2%, respectively. The peritoneal cancer index in 152 patients after two PIPACs decreased, remained stable, or increased in 24.3%, 41.4%, and 34.2%, respectively. Tumour markers (available in 56 patients) decreased in 46.4% and increased in 48.2% of patients. Histological analysis showed regression, mixed response, or absent response in 26.7%, 31.8%, and 41.5% of patients, respectively. Median overall survival from time of PM diagnosis was 17.0 months (95% CI 13.4-20.6) in gastric adenocarcinoma (N=38), 19.0 months (95% CI 11.0-27.0) in colorectal adenocarcinoma (N=26), and 25.0 months (95% CI 17.8-32.2) in pancreatic adenocarcinoma patients (N=24).

Conclusion

Aerosolized intraperitoneal chemotherapy is well tolerated and safe, and can be combined with systemic treatment. Repeated procedures result in demonstrable anticancer activity and promising survival. These results warrant formal exploration of PIPAC in randomized comparative trials.

ABSTRACT. Objective: Ovarian cancer (OC) remains the most lethal gynecologic malignancy. Reliable prognostic markers are needed to guide treatment selection in advanced disease. The histopathological growth pattern (HGP) of colorectal peritoneal and liver metastases has been reported as a major prognostic factor but its role in peritoneal metastases from ovarian cancer (PMOC) has not been investigated.

Methods: This single-center retrospective pilot study included women who underwent curative-intent cytoreductive surgery for primary OC with limited peritoneal disease (PCI ≤6). Excised peritoneal nodules were reviewed to characterize HGPs as either pushing (P-HGP) or infiltrating (I-HGP), defined by the tumor–peritoneum interface morphology. The dominant pattern was assigned when ≥51% of the interface displayed the same morphology. Disease-free survival (DFS) and overall survival (OS) were analyzed using Kaplan–Meier and Cox regression models.

Results: Among 75 screened patients, 34 met inclusion criteria. Twenty-two patients (64.7%) exhibited a predominant P-HGP, 10 (29.4%) a predominant I-HGP, and 2 (5.9%) showed mixed patterns. Patients with a P-HGP demonstrated significantly longer OS compared to those with I-HGP (median 126.8 vs. 74 months; p = 0.0286). While DFS was better for P-HGP than I-HGP (33.6 vs. 16.1 months), the difference did not reach statistical significance. BRCA mutation status and upfront surgery were also associated with improved OS.

Conclusions: This study provides the first description of HGP in PMOC and suggests that HGP is a prognostic factor for OS.

ABSTRACT. OBJECTIVE

The oncologic benefit of curative-intent surgery in patients with a high number of colorectal liver metastases (CRLM) remains debated. This study aimed to evaluate the prognostic impact of the number of CRLM and to determine whether a clinically relevant cut-off value could be identified.

METHODS

All consecutive patients who underwent curative-intent liver resection for CRLM between 2005 and 2022 were retrospectively reviewed. Clinicopathological data were collected. Patients were stratified according to the number of liver metastases into predefined categories (1, 2, 3–4, 5–7, 8–9, and ≥10), with additional grouped analyses (1–3, 4–7, and ≥8). Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan–Meier method and compared using the log-rank test. Prognostic factors were analyzed using uni- and multivariable Cox regression models. A predefined subgroup analysis focused on patients with eight or more metastases.

RESULTS

A total of 500 patients were included. Overall, 62% had 1–3 metastases, 22% had 4–7, and 12% had eight or more. Median OS and DFS progressively decreased as the number of CRLM increased, up to eight lesions. No additional prognostic impact was observed beyond this threshold. Five-year OS rates were 45% for patients with 1–3 metastases, 38% for those with 4–7, and 32% for patients with ≥8 metastases. In patients with ≥8 CRLM, right-sided primary tumors and CEA ≥200 ng/mL were independently associated with worse OS.

CONCLUSIONS

In patients undergoing surgery for multiple CRLM, eight metastases appeared to represent a prognostic cut-off value. Beyond this threshold, no further deterioration in postoperative outcomes was observed. The meaningful long-term survival achieved in selected patients with ≥8 CRLM suggests that the number of metastases alone should not be considered an exclusion criterion for curative-intent surgery.

ABSTRACT. Objective Two-stage hepatectomy (TSH) associated or not with portal vein embolization (PVE) is a technical option to resect multiple bi-lobar colorectal liver metastases (CRLM). Yet, a significant proportion of patients fails to complete the second-stage, having therefore no benefit of this aggressive surgical approach. This study, aims to analyze the results of TSH in our series, to evaluate the drop-out rate and the potential predictive factors for failure of this surgical strategy.

Methods We retrospectively analyzed 74 patients with multiple bilateral CRLM treated with a planned TSH between 2005 and 2024. Clinical, radiological, and pathological variables were reviewed. TSH was proposed in these patients due to pure volumetric concern (N=50(69%)) and ill localized lesions (N=23(31%)). We calculated the Paul-Brousse score (from 0 to 4 including CEA >30 ng/mL; size of metastases >40 mm, chemotherapy cycles >12 and progression during first line chemotherapy). Survival was estimated using the Kaplan–Meier method, and factors associated with failure were assessed using univariate and multivariate analyses.

Results Among the 74 patients included, 22 (29.7%) failed to undergo the second-stage. Median overall survival (OS) for the entire cohort was 24 months. The 3-year OS in patients who completed TSH were of 49.5% as compared to 17.1%, in the patients who dropped out (p=0.017). Among patients completing TSH, the median progression-free survival was 12 months. On multivariate analysis, male sex (OR=7.25; [95% CI: 1.71-30.73]; p=0.007) and ill localized lesions (OR=8.38; [95% CI: 2.01-34.98]; p=0.004) were independent predictors of failure.

Conclusions When completed, TSH provides satisfactory results in patients with multiple bilobar CRLM. In approximatively a third of the patients, the second-stage could not be performed. In these cases, the initial non-resectability, at the time of decision, represents the most significant predictive factor for failure.

ABSTRACT. Objective Intra-arterial hepatic chemotherapy (IAHC) is a therapeutic option for patients with unresectable colorectal liver metastases (CRLM), allowing high intrahepatic drug concentrations, improved response rates, and enhanced local control of missed lesions. This study evaluates overall survival (OS) and hepatic recurrence-free survival (HRFS) in patients with initially unresectable CRLM treated with multimodal strategies including IAHC. Methods From a prospective consecutive database (2012–2024) including 167 patients undergoing locoregional treatment for CRLM, 15 patients treated with IAHC were identified. All patients received systemic therapy (ST) prior to hepatic artery catheter placement or liver surgery. Post-ST resectability was assessed allowing residual missing lesions to remain in situ. Demographic, pathological, and oncologic characteristics were recorded, including Fong score, Tumor Burden Score (TBS), and Oslo score. Indications for IAHC, morbidity (Comprehensive Complication Index, CCI), recurrence patterns, OS, and HRFS were analyzed. Results Patients’ demographics are summarized in table 1. After ST, 73% of patients were converted to resectability despite residual missing lesions. Extra-hepatic disease was present in 20%. Mean CEA levels decreased from 406 to 20.4 ng/mL. Disease burden was high (Fong 4–5: 73%; mean TBS: 25.4 and Oslo3–4: 67%). The median interval from ST to first liver procedure was 4.9 months. Indications for IAHC were unresectable missing lesions (73%), high tumor burden (33%), and debulking (20%). Median CCI was 7.8. Complete hepatic clearance was achieved in 87% of patients. Recurrence patterns were extra-hepatic only (20%), liver only (33%), or combined (27%). Median OS was 50.3 months from initial treatment and 39.3 months from first liver procedure; 5-year OS rates were of 37% and 20%, respectively. Median HRFS was 27.4 months. Rectal primary and KRAS mutation showed borderline prognostic impact. Conclusions In highly advanced CRLM, multimodal strategies incorporating IAHC provide meaningful long-term overall and liver-specific survival with acceptable morbidity, supporting its oncologic relevance in selected patients.

ABSTRACT. OBJECTIVE To describe indications, diagnostic concordance, temporal trends, perioperative and long‑term outcomes, and risk factors for severe morbidity after minimally invasive pancreatectomy for pancreatic cystic neoplasms in a nationwide cohort.

METHODS We conducted a nationwide retrospective study of minimally invasive (MI) pancreatectomy for pancreatic cystic neoplasms in adults from 2010 to 2021 under the auspices of the Association Française de Chirurgie. Demographic, operative, pathological and outcome data, postoperative pancreatic fistula (POPF) rates were collected. Logistic regression identified risk factors for POPF grade B/C. Overall survival was estimated using Kaplan–Meier methods.

RESULTS From 2010 to 2021, 1135 MI pancreatectomy were performed for pancreatic cystic neoplasms and increased linearly (p<0.001) over time: 52.2% intraductal papillary mucinous, 33.8% mucinous cystic, 9.7% solid pseudopapillary, 3.7% serous cystadenoma, and 0.6% cystic pancreatic endocrine tumors. Distal pancreatectomy (DP) accounted for 76.8% and pancreaticoduodenectomy (PD) for 10.6%. Robotic approach was progressively adopted. Overall, 34.2% of preoperative suspected diagnoses differed from final pathology. After minimally invasive PD, POPF grade B/C occurred in 22.5%/7.5% of patients, respectively, and 90‑day mortality was 1.7%. After minimally invasive DP, POPF grade B/C were observed in 16.1%/2.4%, with 90‑day mortality of 0.8%. No independent POPF risk factors were identified after minimally invasive PD. Following minimally invasive DP, antiplatelet therapy and higher intraoperative blood loss independently increased severe POPF risk. Clavien-dindo surgical complication >3 rates were 43.4 % and 16.9% after PD and DP, respectively. The 5‑year survival rate for intraductal papillary mucinous neoplasms was 86.2% (95% CI: 71.7–100) after PD and 95.5% (95% CI: 91.7–99.4) after DP; data for other lesions were insufficient to estimate 5‑year survival.

CONCLUSIONS In this nationwide study, minimally invasive pancreatectomy for pancreatic cystic neoplasms expanded steadily, with substantial diagnostic discordance, low 90‑day mortality, excellent long‑term survival, and substantial perioperative morbidity.

ABSTRACT. RESUME: OBJECTIVE: One of the most challenging complications following pancreaticoduodenectomy (PD) is postoperative hemorrhage (POH), often secondary to pancreatic fistula (POPF). Clinically significant POH occurs in 10–15% of PD cases and is associated with increased mortality. Several surgical techniques have been described to reduce POH, including the use of retromesenteric flap (RMF), an omental shield tunneled through the retromesenteric window to cover vascular structures. This study aimed to evaluate the outcomes of RMF compared with standard PD. METHODS: Between 2022 and 2025, patients who underwent PD were retrospectively reviewed from a prospective database. The RMF was implemented in our institution in 2022 and RMF-related complications were recorded to assess procedural safety. Postoperative outcomes were compared between PD with or without RMF, including POH. RESULTS: 229 consecutive patients were included: 99 in the PD-RMF group and 130 in the PD-standard group. Demographic characteristics, vascular reconstruction, and type of pancreatic anastomosis, were comparable between groups. Among 104 RMFs attempted, 99 were successfully performed, resulting in a success rate of 95.2%. RMF-related complications occurred in four patients: superior mesenteric vein compression (n=1, postoperatively died), bleeding from an RMF collateral vessel (n=1), and surinfection of a necrotic RMF component (n=2). Rates of postoperative severe complications, comprehensive complication index, and mortality were similar between groups. The PD-RMF group had fewer grade B/C POH (4% vs. 15.4%, p=0.005) and less delayed gastric emptying (10.1% vs. 28.5%, p<0.001). At multivariable analysis, clinically relevant POPF was independently associated with more POH (OR 8.394, 95% CI 2.768–25.454, p<0.001), whereas RMF use was independently associated with less POH (OR 0.236, 95% CI 0.075–0.744, p=0.014). CONCLUSIONS: The use of a retromesenteric flap during pancreaticoduodenectomy was feasible and safe and was associated with a significant reduction in postoperative hemorrhage. Careful attention to technical details is essential to prevent RMF-related complications.

ABSTRACT. Pseudomyogenic haemangioendothelioma (PMHE) is a rare vascular tumor with intermediate malignancy, infrequently affecting bone. Its diagnosis is challenging due to histological overlap with epithelioid sarcoma and other bone neoplasms, and management strategies are not well established. We report a 15-year-old boy presenting with pain, swelling, and a pathological fracture of the right hallux. Initial imaging revealed an osteolytic lesion, suspected to be benign. Surgical excision with autologous bone grafting was performed, and histopathology confirmed PMHE with over 90% tumor involvement. Staging identified additional osteolytic lesions in the ipsilateral femur, tibia, and fibula, initially raising concern for multifocal disease. Hallux amputation was considered but ultimately deferred. Genetic testing confirmed an ACTB::FOSB gene fusion, supporting the diagnosis. In the absence of established treatment guidelines for recurrent bone PMHE and given the limited data available in the literature, microwave ablation was attempted as a minimally invasive local treatment in order to explore its feasibility and potential role in tumor control. In the absence of established treatment guidelines for recurrent bone PMHE and given the limited data available in the literature, microwave ablation was attempted as a minimally invasive local treatment to explore its feasibility. Disease progression was observed at 6 months of follow-up, highlighting the unpredictable behavior of PMHE in bone. Given the short follow-up and recurrence, no conclusions can be drawn regarding oncological efficacy. Microwave ablation may nonetheless represent a potential option in selected cases where conventional surgery carries significant functional morbidity. Multidisciplinary management and long-term follow-up remain essential.

ABSTRACT. OBJECTIVE Postoperative intra-abdominal adhesions remain one of the most common and clinically significant complications following abdominal and pelvic surgery. Adhesions contribute to adhesive small bowel obstruction (aSBO), chronic abdominal pain, infertility and increased healthcare costs. Despite decades of research, the clinical value and routine adoption of anti-adhesion barriers remains subject to debate. This review aims to critically evaluate the role of anti-adhesion barriers in the prevention of aSBO. METHODS A narrative review of the literature was performed, critically examining the role of anti-adhesion barriers in preventing aSBO, focusing on their mechanisms, efficacy and limitations. Evidence from randomized controlled trials, observational studies, registry data, and cost-effectiveness analyses was assessed. RESULTS Multiple anti-adhesion barriers have demonstrated a consistent reduction in postoperative adhesion formation in clinical trials. Selected barriers have been associated with a statistically significant reduction in clinically relevant outcomes, including aSBO and chronic abdominal pain. Large registry studies indicate a sustained burden of adhesion-related readmissions following intra-abdominal surgery, while real-world utilization of anti-adhesion barriers remains low. Cost-effectiveness analyses suggest potential benefit predominantly in open colorectal surgery. CONCLUSIONS Anti-adhesion barriers reliably reduce postoperative adhesion formation, but their translation into consistent, patient-centered clinical benefit remains incomplete. Current evidence supports a reduction in reoperation for adhesive small bowel obstruction and suggests cost-effectiveness in selected high-risk open colorectal procedures. In contrast, effects on fertility, chronic pain and long-term quality of life remain uncertain. Anti-adhesion barriers should therefore be considered as selective adjuncts rather than routine prophylaxis, with risk-stratified application in patients prone to adhesion-related morbidity. Future progress will depend on standardized outcome reporting, long-term follow-up and continued innovation in biomaterials to align adhesion prevention strategies with meaningful clinical outcomes.

ABSTRACT. OBJECTIVE Roux-en-Y gastric-bypass (RYGB) remains a cornerstone of metabolic bariatric surgery (MBS). This study aimed to assess 5-year follow-up outcomes in terms of weight loss durability, postoperative morbidity, metabolic outcomes, gastroesophageal reflux disease (GERD), and nutritional status after primary laparoscopic RYGB.

METHODS We conducted a retrospective observational study including consecutive adult patients undergoing primary laparoscopic RYGB between 2014 and 2020 in a certified bariatric center. Patients with prior bariatric surgery were excluded. Outcomes were assessed at standardized intervals up to 5 years and included body mass index (BMI), percent excess and total weight loss (%EWL, %TWL), remission of type 2 diabetes mellitus (T2DM), GERD outcomes, major postoperative complications (Clavien-Dindo ≥ III), readmissions, and biochemical nutritional parameters.

RESULTS A total of 358 patients were included with 75.4% females and mean age of 47.6 ± 11.4 years. Baseline BMI was 40.2 ± 3.8 kg/m². Mean %EWL reached 97.1 ± 23.4% at 2 years and remained at 84.0 ± 30.0% at 5 years. Major postoperative complications occurred in 7.3% of patients, including one postoperative death (0.3%). Readmission rates were 14.5% within 1 year and 28.7% within 2 years. Among patients with baseline GERD, clinical remission at 1 year was observed in 70.0%. T2DM remission was observed in 56.3% of patients at 2 years and in 42.1% at 5 years, while hypertension remission was achieved in 53.0% and 43.8%, respectively. Despite a high rate of vitamin supplementation (95.2% at 5 years), nutritional abnormalities were frequent at long-term follow-up, including calcium deficiency in 14.4% of patients and hypoalbuminemia in 52.9%.

CONCLUSIONS In routine clinical practice, RYGB provides durable 5-year weight loss with meaningful metabolic improvement and effective GERD control. However, its benefits are counterbalanced by non-negligible morbidity, frequent readmissions, and persistent nutritional risk, underscoring the need for structured long-term multidisciplinary follow-up.

ABSTRACT. Background: Minimally invasive direct coronary artery bypass (MIDCAB) has become a valuable option for revascularization of proximal left anterior descending (LAD) artery disease. Robotic assistance enhances surgical precision, reduces invasiveness, and broadens eligibility to patients with complex anatomy and high surgical risk.

Case Presentation: We report the first two cases of successful robotic-assisted MIDCAB in patients with prior right-sided pneumonectomy, a population traditionally excluded from minimally invasive cardiac surgery due to altered thoracic anatomy and reduced pulmonary reserve. Both patients underwent preoperative imaging and pulmonary function assessment to guide individualized surgical planning. Despite high-risk profiles and standby veno-venous extracorporeal membrane oxygenation (VV-ECMO), procedures were completed without extracorporeal support. Robotic-assisted left internal mammary artery (LIMA) harvesting and end-to-side anastomosis to the LAD were successfully performed through a mini-thoracotomy. Both patients had uneventful postoperative recoveries, with early extubation and discharge without cardiopulmonary complications.

Conclusion: These cases demonstrate that robotic-assisted MIDCAB is technically feasible and clinically safe in post-pneumonectomy patients, extending the indications of minimally invasive coronary revascularization to patients with complex thoracic anatomy and limited pulmonary reserve. Meticulous preoperative planning and intraoperative strategy are essential for success.

ABSTRACT. Objective To present a rare case of a small bowel sarcoma in a 65-year-old, male patient.

Results A 65-year-old male with no relevant medical history presented with several weeks of abdominal discomfort, initially attributed to stress. Physical examination revealed an abdominal mass. A CT scan was performed, showing an abdominal mass of 20cm. A biopsy was performed, which suggested an undifferentiated pleomorphic sarcoma. An explorative laparotomy with surgical resection of the mass was conducted. The resected mass weighed 1613 grams, had a smooth surface, and measured 23 × 20 × 8 cm. Further pathological examination showed that the tumor originated from the subserosa of the small intestine. Histological analysis confirmed the diagnosis of undifferentiated pleomorphic sarcoma. Pathology showed that colouring of DOG 1, desmine, CD 117/31/34/45, MDM-2 and EMA are negative.

Conclusion Sarcomas of the small intestine are rare, accounting for only about 10% of small intestine tumors. A small bowel sarcoma is usually classified as a gastrointestinal stromal tumor, finding his origin in the cells of Cajal. In our patient DOG-1, CD 117 and desmine are negative, making it unlikely to be a GIST. This case highlights a rare undifferentiated pleomorphic sarcoma originating from the small intestine.

ABSTRACT. BACKGROUND Internal herniation of the small bowel beneath skeletonized pelvic vessels is an extremely rare but potentially life-threatening complication following pelvic lymph node dissection. We report a case of acute small bowel obstruction caused by an internal hernia beneath the left external iliac artery after robotic-assisted radical prostatectomy with extended pelvic lymph node dissection. CASE PRESENTATION: A 74-year-old man presented with acute lower abdominal pain and abdominal distension. His medical history included a robotic-assisted radical prostatectomy with pelvic lymph node dissection for prostate cancer (pT3aN0R0, Gleason score 4 + 5). On admission, physical examination revealed a tympanitic abdomen with tenderness in the left lower quadrant. Contrast-enhanced computed tomography demonstrated dilated, fluid-filled small bowel loops with multiple transition points, most pronounced posterior to the left external iliac artery, as well as associated left-sided hydronephrosis. Given the suspicion of closed loop obstruction, urgent surgical exploration was performed. Laparoscopy was initiated but converted to laparotomy due to intra-abdominal findings, including hemorrhagic ascites. Intraoperatively, a closed-loop obstruction was identified, with approximately 70 cm of ileum incarcerated beneath the left external iliac artery through a 3–4 cm defect. The bowel was viable after reduction. The defect was closed using a peritoneoraphy to prevent recurrence. Postoperatively, antibiotic therapy was administered for twelve days due to aspiration during extubation. The postoperative course was otherwise uneventful and the patient was discharged on postoperative day eight. CONCLUSION: Internal hernia beneath the external iliac vessels is a rare but clinically significant complication following robotic-assisted radical prostatectomy with pelvic lymphadenectomy. Awareness of this entity and prompt surgical intervention are essential to prevent bowel ischemia and associated morbidity.

ABSTRACT. Background Acute appendicitis (AA) is one of the most common cause of acute abdomen worldwide, with appendectomy remaining the standard of care. While laparoscopic appendectomy is now widely adopted, debate persists regarding the optimal technique for mesoappendix transection. In particular, the comparative impact of isolated appendectomy versus total mesoappendix transection on postoperative outcomes remains insufficiently defined. Objective This study aimed to compare postoperative clinical outcomes and economic parameters between isolated appendectomy and appendectomy with mesoappendix transection performed at the appendix base in patients undergoing emergency surgery for acute appendicitis. Methods We conducted a retrospective comparative study including patients aged older than 16 years who underwent emergency appendectomy for AA between 2017 and 2025 at our Institution Patients were divided into two groups: (1) isolated appendectomy with progressive mesoappendix dissection from the tip to the caecal base, and (2) appendectomy with mesoappendix dissection starting from the caecal base and transected together with the appendix base. Demographic, clinical, operative, postoperative, and pathological data were collected, including operative time, length of stay, conversion to laparotomy, drain placement, postoperative complications, need for CT-guided drainage, readmission rates, and histopathological findings. Results Among 1023 patients who underwent appendectomy during the study period, 910 met the inclusion criteria and were analyzed. Baseline demographic and clinicopathological characteristics were comparable between the two groups. No statistically significant differences were observed between isolated appendectomy and appendectomy with mesoappendix transection regarding operative time, length of hospital stay, postoperative complications, conversion rates, drain placement, readmissions, or need for percutaneous drainage. Conclusion In this large retrospective cohort, isolated appendectomy and appendectomy with mesoappendix transection demonstrated comparable postoperative and economic outcomes. Both techniques appear safe and effective in the management of acute appendicitis. The choice of technique may depend on surgeon preference and intraoperative findings rather than expected differences in clinical outcomes.

ABSTRACT. Purpose: Hemorrhoidal disease is a common anorectal condition. In surgical treatment, open hemorrhoidectomy is the golden standard, nevermore the procedure knows a substantial risk of complications, postoperative pain, and discomfort. However, Laser Hemorrhoidoplasty (LHP) is a minimally invasive procedure that might offer advantages such as shorter operative time, lower risk of complications, and quicker return to daily activities compared to conventional surgical methods. We aimed to analyze the clinical outcomes and recurrence rate of LHP in our center for grade II-IV hemorrhoidal disease. Primary outcomes were postoperative Visual Analogue pain scores patients and patient satisfaction. Secondary outcomes were complication rate; duration of hospital stay and recurrence rate.

Methods: Our study was conducted on 132 patients (72% male, average age 52.77 years) with hemorrhoidal disease grade II-IV who underwent Laser Hemorrhoidoplasty (LHP) in our clinic between January 2021 and June 2025

Results: Postoperatively, the mean Visual Analogue Score was zero at discharge, after one week and after one month. Of all patients, 95.5% reported to be satisfied with the postoperative results. Twelve patients (9.1%) suffered from a complication, whereof three patients (2.3%) were readmitted and for one patient reintervention was needed. The majority of patients (94.7%) were able to leave the hospital the same day. In total five patients (3.8%) suffered from relapse and required surgical treatment.

Conclusion: In our experience, LHP is a safe procedure for hemorrhoidal disease that can be performed in day surgery, leading to less pain and discomfort postoperatively and high patient satisfaction.

ABSTRACT. Objectives Primary Pigmented Nodular Adrenocortical Disease (PPNAD) is a rare cause of ACTH-independent Cushing’s syndrome, characterized by multiple pigmented adrenal micronodules producing excess cortisol. It is commonly associated with Carney Complex (CNC). The isolated form of PPNAD (i-PPNAD) is diagnostically challenging due to nonspecific symptoms and often normal imaging.

Methods We describe the case of a 26-years-old previously healthy male athlete who presented with insomnia, palpitation, progressive weight gain and arterial hypertension. Additionally, we conducted a scoping review (MEDLINE® PubMed, November 2025) focusing on iPPNAD.

Results The patient showed both biochemical and clinical signs of Cushing’s syndrome, including unsuppressed cortisol on low- and high-dose dexamethasone suppression tests and undetectable ACTH. CT imaging showed normal adrenal morphology. Bilateral laparoscopic adrenalectomy was performed, and histology confirmed nodular adrenocortical hyperplasia with pigmented cells. Our literature review identified 33 case reports describing 38 patients with iPPNAD (1986-2025). The mean age was 24 years and 60.5% were women. Weight gain and hypertension were the most common presenting features. Imaging varied widely: six reports described completely normal CT or MRI scans, while others showed ‘string-of-beads’ pattern of small nodules with cortical atrophy. Most patients underwent bilateral adrenalectomy.

Conclusion Isolated PPNAD is a rare but important cause of ACTH-independent Cushing’s syndrome in young patients. Diagnosis requires clinical suspicion, hormonal evaluation, and histological confirmation. Bilateral adrenalectomy remains the mainstay of treatment.

ABSTRACT. Objective

Endoscopic ultrasound–guided gastroenterostomy (EUS-GE) is an emerging minimally invasive alternative for surgical gastroenterostomy in patients with gastric outlet obstruction. We report a rare complication following EUS-GE that required surgical management.

Methods

A 59-year-old man underwent EUS-GE using a lumen-apposing metal stent (LAMS; Hot AXIOS™) for gastric outlet obstruction caused by locally advanced pancreatic carcinoma. The procedure was uneventful. Six days later, the patient was re-admitted with acute intestinal obstruction, presenting with vomiting, abdominal distension, and acute renal failure due to dehydration. Abdominal computed tomography revealed an acute mesenteric volvulus with secondary closed-loop small bowel obstruction, without signs of intestinal ischemia. The pathognomonic mesenteric whirl sign was present. After admission to the intensive care unit and placing an nasogastric tube for decompression, semi-urgent laparoscopic exploration was performed the day after. A patent EUS-GE was identified 10–15 cm distal to the angle of Treitz. The small bowel distal to the EUS-GE had herniated from media to lateral through the mesenteric defect created by the gastroenterostomy, consistent with a Petersen-type internal hernia. A torsion of the efferent jejunal limb adjacent to the LAMS was observed. The herniation was reduced, and to prevent recurrence, an additional surgical gastroenterostomy was created 20–30 cm more distally in an omega-loop configuration using a side-to-side stapled technique. The Petersen space was closed with nonresorbable unidirectional barbed suture.

Results

The postoperative course was complicated by gastroparesis and aspiration pneumonia. The patient was discharged on postoperative day 16 with normal tolerance of solid food. Neoadjuvant chemotherapy was initiated five weeks postoperatively.

Conclusion

Although EUS-GE is minimally invasive, it may rarely result in internal herniation through Petersen’s space, resembling complications seen after surgical gastroenterostomy. Early recognition and prompt surgical intervention are crucial. In selected cases, construction of a more distal surgical gastroenterostomy may be required to prevent recurrent torsion and obstruction.

ABSTRACT. OBJECTIVE Melanoma is the carcinoma that most frequently spreads to gastrointestinal tract, particularly the jejunum and ileum. It can lead to intussusception, obstruction, perforation, or gastrointestinal bleeding. If diagnosed, surgical resection is most often indicated.

METHODS We report a 40 year-old man with only a medical history of corneal-conjunctival melanoma in his left eye. This lesion was surgically resected by alcohol epitheliectomy, cryotherapy and amniotic membrane graft. Additional treatment with brachytherapy was also performed due to an incomplete resection. Ten months later, a follow-up PET-CT showed two hypermetabolic jejunal lesions with mesenteric lymphadenopathy while patient was asymptomatic. An upper digestive enteroscopy was carried out and highlighted a 20mm blackish and budding tumor of the proximal jejunum. Biopsies were compatible with melanoma metastases. Patient underwent surgical exploration for double segmental jejunal resection with mesenteric lymph node dissection and a manual end-to-end jejuno-jejunal anastomosis was performed.

RESULTS Postoperative was uneventful and pathology confirmed known melanoma metastases with R0 resection and lymph node invasion. Two months after surgery the patient relapsed with jejunal and cervical suspicious lesions on PET-CT. Adjuvant treatment with immunotherapy (Pembrolizumab) was initiated immediately afterward but after 3 months, the jejunal lesion increased in size. Patient underwent a new small bowel resection combined with a cervical lymph node dissection. All the lesions were melanoma metastases with R0 resection. A new adjuvant treatment by dual targeted therapy (Dabrafenib + Trametinib) was performed for one year with no local or distant recurrence sign at the end of the treatment.

CONCLUSIONS Small bowel metastases can rapidly occur after primary melanoma’s treatment and several relapses are possible. Even in cases of metastatic melanoma, surgery combined to immuno or targeted therapy can lead to good results.

ABSTRACT. Introduction: Colonic endometriosis is a rare disease in postmenopausal women. It is often initially confused with a malignant tumour or chronic inflammatory bowel disease (IBD). We present the case of a 78-year-old female patient with p-ANCA positivity mimicking IBD, complicated by corticosteroid-induced perforation.

Case presentation: A 78-year-old woman with no gynaecological history of endometriosis presented with recurrent rectal bleeding and abdominal pain in the lower left quadrant. Imaging revealed colitis of the left colon, sigmoid colon and rectum with wall thickening. Laboratory tests showed elevated CRP (200 mg/L), Grade IV iron deficiency anaemia, and positive p-ANCA, suggesting inflammatory bowel disease or an infectious cause. Despite prolonged treatment with antibiotics and systemic corticosteroids during her hospitalisation, she developed progressive rectosigmoid stenosis. After a month and a half, acute abdomen developed. An abdominal CT scan showed sigmoid perforation requiring a Hartmann's procedure. Histopathological examination revealed rectosigmoid diverticulosis associated with the presence of florid colonic endometriosis lesions, confirmed by CD10 immunostaining, without malignancy.

Conclusion: Colonic endometriosis should be considered in the differential diagnosis of unexplained colitis in postmenopausal women. Prolonged treatment with corticosteroids without a definitive histological diagnosis may mask the underlying pathology, with a risk of perforation. A positive p-ANCA test should not automatically lead to a diagnosis of inflammatory bowel disease. A multidisciplinary approach with early surgical consultation is essential when the clinical course is atypical and refractory to standard treatment.

ABSTRACT. Background: Pelvic exenteration (PE) is a surgical procedure for complex malignant disease of the pelvis with major morbidity, but increasing long-term survival. Quality of life (QoL) is becoming more important for survivorship, and this can be explored in-depth through qualitative research. The aim of this study was to provide an overview of published qualitative research regarding PE. Methods: Protocol with search strategies were registered at Open Science Framework, following the PRISMA-extension for scoping reviews. EMBASE, PubMed, Cochrane Library, Web of Science, Open Evidence and Google Scholar were searched until 12/2025 by two independent researchers. Qualitative studies with >50% of included patients undergoing PE were considered. Study selection (Rayyan QCRI), data extraction, Critical Appraisal of Skills Programme (CASP) were performed by two independent reviewers. Results: Sixteen studies published between 1972-2025 were included, comprising 257 patients. Most patients had colorectal (n=126) or gynaecological (n=84) tumours. CASP appraisals ranged between 4-10, with higher scores in studies published from 2000 onwards. All studies used qualitative methodology, with one study using mixed-methods approach. Thematic analysis was the most used type of qualitative analysis (n=6), followed by narrative (n=4), phenomenological (n=4), and grounded theory (n=2). Themes were subdivided in psychological (n=23), morbidity/mortality (n=14), life after surgery (n=10), information/education (n=6), sexuality (n=6), nutrition (n=5), social (n=5), partner/relationship (n=4), body/self-image (n=3), occupation/hobbies (n=3) and other (n=14). All studies reported on QoL, except one that solely reported on dietary intake. No study reported on adolescents and young adults or financial toxicity. Most studies reported a decline in QoL postoperatively, with recovery to baseline over time. The negative impact on sexual function was permanent and reported more frequently before 2005. Conclusions: Qualitative research has the major advantage of in-depth QoL analysis, but it has not been applied frequently in PE research. This scoping review identified current gaps of qualitative research in PE.

ABSTRACT. OBJECTIVE We present a rare and significant complication of endoscopic retrograde cholangiopancreatography (ERCP) involving misplacement of a biliary stent into the portal vein, emphasizing diagnostic challenges, management strategies, and outcomes.

METHODS A patient in his fifties presenting with abdominal pain and jaundice underwent imaging that revealed cholestasis and cholecystitis without biliary dilatation. ERCP was performed due to suspected bile duct pathology, complicated by diffuse bleeding requiring deployment of two overlapping biliary metal stents for hemostasis. Subsequent clinical deterioration with pancreatitis and persistent cholestasis prompted cross-sectional imaging. A CT scan and percutaneous cholangiography (Fig. 1) were used to evaluate the cause of the patient’s symptoms and reveal the stent position.

RESULTS Imaging demonstrated that a biliary stent had perforated the common bile duct and migrated into the portal venous system, reaching the right portal vein branch. Initial surgical exploration was considered but deferred due to severe pancreatitis. The patient was discharged with the malpositioned stent in place, remaining asymptomatic. After six months, a combined endoscopic and transsplenic radiological approach allowed safe retrieval of the stent without hemorrhagic complications, and an appropriately placed biliary stent was inserted. At one-year follow-up, the biliary stent was removed without further adverse events.

CONCLUSIONS Biliary stent migration into the portal vein is an exceedingly rare but potentially serious complication of ERCP. Recognition on cross-sectional imaging and a multidisciplinary approach enable safe, minimally invasive management. This case underscores the need for vigilance in post-ERCP care and illustrates a successful delayed stent retrieval strategy.

ABSTRACT. OBJECTIVE Single Anastomosis Sleeve Ileal bypass (SASI) is a hybrid bariatric procedure combining sleeve gastrectomy with partial diversion of the alimentary flow toward the distal ileum. It is proposed for the treatment of morbid obesity and obesity-related comorbidities. This study aimed to prospectively evaluate the postoperative efficacy and safety of SASI in an expert center. METHODS This prospective monocentric study included all consecutive patients who underwent laparoscopic SASI between June 2022 and August 2025. The standardized technique consisted of sleeve gastrectomy followed by a single ileo-gastric anastomosis performed 300 cm proximal to the ileocecal valve. All patients followed an enhanced recovery after surgery protocol. Outcomes included weight loss, length of hospital stay, morbidity and mortality at 30 and 90 days, postoperative complications classified according to the Clavien–Dindo classification, and evolution of obesity-related comorbidities. RESULTS A total of 101 patients were included (71 women, 30 men), with a mean age of 39 years (range 18–72). Preoperative comorbidities included arterial hypertension (33.7%), type 2 diabetes mellitus (17.8%), and obstructive sleep apnea syndrome (55.4%). Mean total weight loss at 12 months was 32.3%. Median length of hospital stay was 2 days (range 1–3). Postoperative mortality at 30 and 90 days was 0%. Severe complications (Clavien–Dindo grade III–IV) occurred in approximately 2–3% of patients. Three patients required restoration of intestinal continuity, one for refractory gastroesophageal reflux disease and two for hypoproteinemia. Resolution of obstructive sleep apnea syndrome, arterial hypertension, and type 2 diabetes mellitus occurred in 23.2%, 14.7%, and 11.1% of affected patients, respectively. CONCLUSIONS In this prospective monocentric experience, SASI provided substantial weight loss with a favorable safety profile, including low postoperative morbidity, no mortality, and short hospital stay. Improvement of obesity-related comorbidities was observed. These findings support SASI as a safe and effective bariatric surgical option.

ABSTRACT. OBJECTIVE Patients with previous antireflux surgery who develop morbid obesity represent a complex clinical challenge. Conversion to Roux-en-Y gastric bypass has been proposed as a revisional option providing both weight loss and reflux control. This study evaluates long-term weight loss, reflux outcomes and gastrointestinal symptoms after conversion of previous antireflux surgery to Roux-en-Y gastric bypass.

METHODS A retrospective single-center study was performed including patients who underwent conversion from previous antireflux surgery to Roux-en-Y gastric bypass between 2005 and the present. Thirty-one patients were included for long-term weight analysis, of whom sixteen completed long-term follow-up questionaire including the gastrointestinal symptom rating scale questionnaire (GSRS). Weight outcomes, reflux symptoms and postoperative complications were assessed.

RESULTS Thirty-one patients with a history of antireflux surgery were included, comprising 30 Nissen fundoplications and 1 Belsey-Mark procedure. Mean interval between antireflux surgery and conversion was 11.3 years. Conversion was performed for morbid obesity in all patients, with persistent reflux symptoms present preoperatively in 4 cases. Mean age at Roux-en-Y gastric bypass was 48.6 years and mean preoperative body mass index was 38.6 kg/m². At a mean follow-up of 6.92 years after conversion, mean body mass index decreased to 27.2 kg/m², with a mean total weight loss of 29.5% and excess weight loss of 86.3%. Of the 16 patients with symptom follow-up, 12 were reflux-free after surgery, while only 1 patient developed recurrent reflux symptoms. Mean postoperative gastrointestinal symptom rating scale score was 23.3. Four postoperative complications were observed, with no surgery-related mortality.

CONCLUSIONS Conversion of previous antireflux surgery to Roux-en-Y gastric bypass results in durable and clinically meaningful long-term weight loss with effective reflux control. In addition, postoperative gastrointestinal symptoms are acceptable and complication rates remain low, supporting this revisional approach as a safe and valuable option in carefully selected patients with morbid obesity after antireflux surgery.

ABSTRACT. OBJECTIVE

The aim of this study is to evaluate the role of robotic surgery in right hemicolectomy for cancer in elderly patients, assessing its potential to reduce surgical trauma, blood loss, conversion rates and postoperative complications, promoting a faster postoperative recovery in this high-risk and frail population.

METHODS

This is a retrospective monocentric study based on a prospective database of right hemicolectomies for colon cancer. Between January 2023 and December 2025, 160 right hemicolectomies for colon cancer were performed; among these, 40 were performed using a robotic-assisted technique (Da Vinci X). Patients aged ≥65 years were included and characterized according to their frailty index (mFI-5), ASA score, and ECOG performance status. Primary endpoints included 30-day mortality, postoperative morbidity (Clavien-Dindo classification), length of stay (LOS), and intensive care unit (ICU) admission.

RESULTS

Of the 40 robotic-assisted right hemicolectomies, 24 were performed in patients aged ≥65 years: 8 (33.3%) were in the 65-74 age group and 16 (66.7%) were aged ≥75 years. Median age was 82 years (range: 66-90). The 30-day mortality rate was 4.2% (1 patient, 84 years old, mFI-5 = 3). Overall morbidity was 16.7% (4 patients), all in the ≥75 age group, with no reoperation required. Complications were classified according to Clavien-Dindo: 23 grade 0-I, 1 grade V. Median LOS was 6,5 days (range: 4-17). 16 patients (66.7%) remained hospitalized for more than 7 days, often due to awaiting social placement rather than medical reasons. 1 patient required a 48h stay in the ICU.

CONCLUSIONS

These results demonstrate that robotic-assisted right hemicolectomy for colon cancer is a safe and feasible procedure in elderly patients, consistent with recent literature. Prolonged hospital stay was primarily related to social factors rather than surgical complications, highlighting the importance of a multidisciplinary approach integrating geriatric and social care. Larger prospective studies are warranted to confirm these findings.

ABSTRACT. Abstract Objective: Gastroptosis is a rare and underrecognised cause of chronic postprandial abdominal pain and malnutrition. Diagnosis is frequently delayed due to nonspecific symptoms and the limitations of conventional supine imaging, and optimal surgical management remains undefined. This report aims to highlight the diagnostic value of upright imaging and to describe a durable surgical approach for severe, refractory disease. Methods: We describe the case of a 57-year-old woman presenting with progressive postprandial discomfort, early satiety, fear of eating, and significant weight loss of 22 kilograms, resulting in a body mass index of 17.9 kilograms per square meter. Extensive investigations, including computed tomography, upper gastrointestinal endoscopy, esophageal manometry, and gastric emptying studies, were unrevealing. An upright barium swallow study was performed to assess gravity-dependent pathology. Following multidisciplinary discussion, laparoscopic subtotal gastrectomy with Roux-en-Y gastrojejunal reconstruction was undertaken. Results: The upright barium swallow demonstrated marked caudal displacement of the stomach into the pelvis, establishing the diagnosis of symptomatic gastroptosis. Surgery was completed laparoscopically without intraoperative complications. Postoperative recovery was uneventful, with complete resolution of postprandial pain and early satiety. The patient resumed normal oral intake and achieved sustained weight gain. At two-year follow-up, symptom relief remained durable with no evidence of recurrent abdominal discomfort or nutritional compromise.

Conclusions: Upright imaging is essential for the diagnosis of gastroptosis, as gravitational gastric descent may remain occult on standard supine studies. In carefully selected patients with severe, refractory symptoms, laparoscopic subtotal gastrectomy with Roux-en-Y reconstruction can provide a safe and effective surgical solution with durable functional improvement. Further studies are warranted to better define patient selection and optimal operative strategies for this uncommon condition.

ABSTRACT. INTRODUCTION Traumatic diaphragmatic injuries are relatively rare, with an incidence ranging from 1-8% of traumatic injuries, but can be associated with a high mortality rate of 15-35%. CT-scan is considered the gold standard imaging, however diagnosis and management are often delayed. Surgical approach varies depending on the associated injuries and severity of the diaphragmatic injury. CASE REPORT We present a case involving a 29 year old male who sustained a high energetic blunt trauma. Imaging revealed a right sided diaphragmatic rupture, lung consolidation, a small liver laceration and intra-thoracic herniation of bowel and liver. The large diaphragmatic defect was closed with separate sutures via right sided thoracotomy. Postoperative course was uneventful and the patient was discharged 11 days after surgery. CONCLUSIONS Thoracotomy is a valuable approach for closing right sided diaphragmatic ruptures in patients presenting with large isolated defects after blunt trauma.

ABSTRACT. OBJECTIVE

Acute hepatic compartment syndrome is a rare but life-threatening condition resulting from increased intrahepatic pressure causing vascular compromise and acute liver failure. Surgical decompression is generally considered the standard treatment. We report a case of hepatic compartment syndrome following rupture of a hepatic artery pseudoaneurysm successfully managed conservatively after effective endovascular hemostasis.

METHODS A 75-year-old woman underwent elective laparoscopic cholecystectomy complicated by postoperative surgical site collection requiring interventional drainage. On postoperative day (POD) 16, CT revealed a subcapsular hepatic hematoma. On POD21, she developed refractory hypertension and liver cytolysis. Contrast-enhanced CT demonstrated a right branch of hepatic artery pseudoaneurysm with hematoma enlargement. Acute deterioration occurred overnight with an acute abdomen. Emergency repeat CT demonstrated pseudoaneurysm rupture, extensive hepatic hypoperfusion, and massive cytolysis (AST 1,756 IU/L; ALT 776 IU/L). Urgent selective transarterial embolization of the right branch of hepatic artery achieved hemostasis while preserving residual perfusion. A diagnosis of hepatic compartment syndrome was established and despite biochemical worsening (AST 11,057 IU/L, ALT 3,926 IU/L, INR 1.4, factor V 49%), conservative management was initiated in the intensive care unit with close doppler monitoring, transfusion support, and thromboelastometry-guided therapy.

RESULTS No surgical decompression was required. Liver function progressively improved from POD23 onward with spontaneous normalization of coagulation and cytolysis markers. The patient was discharged on POD31 in good clinical condition. Follow-up CT at two months demonstrated near-complete resolution of the hematoma and restored hepatic perfusion.

CONCLUSIONS Although surgical decompression remains the recommended first-line treatment for hepatic compartment syndrome, this observation suggests that conservative management may be feasible in exceptionally selected cases after effective hemostasis and under strict multidisciplinary monitoring.

ABSTRACT. OBJECTIVE: Floating thrombus of the thoracic aorta is a rare and potentially life-threatening condition associated with a high risk of systemic embolization. Management is particularly challenging in patients with solid organ transplantation due to the need to preserve graft function. This report describes the feasibility and short-term outcome of a hybrid surgical and endovascular approach in a renal transplant recipient. CASE PRESENTATION AND METHODS: A 66-year-old female with a history of two renal transplantations presented with right flank pain evolving over five weeks. Contrast-enhanced computed tomography revealed a floating thrombus of the thoracic aorta associated with embolic material in the iliac arteries, distal embolization to mesenteric collateral branches, and partial hypoperfusion of the lower pole of the renal graft. A hybrid strategy was performed. Through a midline laparotomy, infrarenal aortic and iliac thrombectomy was achieved via longitudinal arteriotomy. During aortic clamping, renal graft protection was provided by continuous cold saline perfusion through the right iliac artery. The procedure was completed with Fogarty thrombectomy and thoracic endovascular aortic repair using a 30 × 115 mm stent graft. RESULTS: The procedure was technically successful. No intraoperative or postoperative ischemic complications occurred. Renal graft function was preserved, and no recurrent embolic events were observed during short-term follow-up. The overall postoperative course was uneventful. CONCLUSIONS: A hybrid approach combining open thrombectomy, targeted renal graft protection, and thoracic endovascular aortic repair is a feasible and effective treatment option for floating thrombus of the thoracic aorta in renal transplant recipients, allowing embolic control while preserving graft function with favorable short-term outcomes.

ABSTRACT. OBJECTIVE This case report describes a 79-year-old man with history of Siewert type III esophageal adenocarcinoma diagnosed in 2023, treated with neoadjuvant chemotherapy followed by minimally invasive esophagectomy (Ivor-Lewis) and adjuvant chemotherapy. In January 2025, local recurrence was detected in a cervical lymph node. This recurrence was non-responsive to chemo- and radiotherapy, and no targetable molecular alterations were identified. Due to progressive tumor growth during follow-up and strong patient preference, salvage surgery was indicated. The objective of surgery was R0-resection. METHODS A cervical incision was made, and the tumor was resected with 10-cm segment of esophagus, dorsally the prevertebral fascia was excised. While the recipient vessels (internal jugular vein and superior thyroid artery) were prepared, a free ileal conduit measuring 15 cm was harvested from the terminal ileum via laparotomy, pedicled on the ileocolic artery. A distal circular anastomosis was performed between the ileum and thoracic esophageal remnant. Microvascular anastomosis of the artery and vein was performed. Finally, the proximal anastomosis was manually fashioned using interrupted sutures. The proximal 5 cm of the ileal segment was left as a monitoring (“witness”) segment to assess vascularization and was excised one week later. RESULTS Initial postoperative outcomes were favorable, with good conduit vascularization. Successful weaning was initiated on day 1 postoperative. Gastroscopy showed a well vascularized neo-esophagus (pharynx, ileum, thoracic esophagus, gastric tube). Postoperative hematoma and chyle leak required surgical re-exploration during hospitalization. A Lipiodol lymphangiography was performed to address the chyle leak. CONCLUSIONS A free ileal conduit can be safely used for salvage surgery in selected cases. Due to the proximal localization of the recurrence, both distal and proximal anastomoses could be performed through a cervical approach. This avoided thoracotomy and colonic interposition, both have high complication rates.

ABSTRACT. OBJECTIVE A replaced common hepatic artery (rCHA) arising from the superior mesenteric artery (Michels type 9) is a rare but clinically important variant during pancreatic head resections. Although multiple surgical strategies have been described, an up-to-date synthesis and standardized management framework are lacking.

METHODS We retrospectively analyzed patients with Michels type 9 rCHA undergoing pancreaticoduodenectomy (PD) or total pancreatectomy (TP) at a high-volume pancreatic center between January 2013 and January 2025. Preoperative, perioperative, postoperative and oncologic outcomes were descriptively analyzed. We combined institutional experience with current literature to propose an individualized management algorithm.

RESULTS Five patients underwent pancreatic resection (PD, n=4; TP, n=1) via open (n=3) or minimally invasive (n=2) approaches. The rCHA course was antepancreatic, retropancreatic, or intrapancreatic. The artery was preserved in three patients. Two required rCHA resection: splenic artery transposition (n=1) or preoperative common hepatic artery embolization enabling safe ligation with right gastric artery preservation (n=1).

CONCLUSIONS Surgical management of patients with rCHA depends on both arterial course and the relationship to the tumor. We propose an algorithm for rCHA management that prioritizes oncological radicality and safety, emphasizing arterial preservation and reserving embolization-assisted ligation or autologous reconstruction when resection is required.

ABSTRACT. OBJECTIVE

Bezoars are accumulations of indigestible material within the gastrointestinal tract. Among them, trichobezoars consist predominantly of ingested hair and can lead to serious complications such as bowel obstruction, perforation and intussusception. Their clinical presentation is often nonspecific, especially in young children, often leading to delayed diagnosis.

METHODS

A 3-year-old boy with known verbal and social developmental delay under psychiatric follow-up, presented with one week of abdominal pain, fecaloid vomiting and acute respiratory compromise secondary to abdominal distension. Imaging revealed dilated small bowel loops, intra-abdominal free fluid, and free air suggestive of obstruction with perforation. Emergency midline laparotomy revealed purulent peritoneal fluid and an obstructing mobile mass in the proximal jejunum. Enterotomy allowed removal of two bezoars composed of hair and textile material. A perforation near the ligament of Treitz required limited segmental resection with primary anastomosis. An additional large gastric trichobezoar was removed via gastrotomy. Abdominal drains were placed near the closed gastrotomy and Treitz region.

RESULTS

Postoperative management included broad-spectrum antibiotics guided by intraoperative cultures. The clinical course was complicated by wound dehiscence, managed conservatively. Given the underlaying feeding aversion, enteral tube feeding was continued on an outpatient basis. At one-month follow-up, the wound showed satisfactory healing. However, oral intake remained limited, requiring ongoing nutritional support via enteral tube feeding. Multidisciplinary follow-up with pediatric neurology, psychiatry and developmental specialists was established.

CONCLUSION

Trichobezoar should be suspected in young children with developmental disorders presenting with acute abdominal symptoms. Delayed diagnosis may lead to severe complications such as perforation. Prompt surgical management and multidisciplinary follow-up are crucial for optimal outcomes and prevention of recurrence.

ABSTRACT. OBJECTIVE Neuroendocrine carcinoma are agressive tumors with a median overall survival of one year, often diagnosed at a metastatic stage. Primary sites are commonly the gastrointestinal tract and lungs, although some cases have an occult origin. We report an unusual case of metastatic high-grade neuroendocrine carcinoma with an indolent clinical course. METHODS We report the case of an 83-year-old patient with history of ischemic stroke and surgical resection of localized prostate adenocarcinoma without adjuvant therapy. Excision of an enlarged right inguinal lymph node revealed a high-grade neuroendocrine carcinoma. An extensive work-up including chromogranin A, prostate-specific antigen measurement, thoracoabdominal computed tomography, 68Ga-DOTATOC PET/CT, and upper endoscopic ultrasound was performed. Elevated chromogranin A levels were observed, and 68Ga-DOTATOC PET/CT demonstrated a hypermetabolic mass beneath the right trapezius muscle, without other lesions. Resection confirmed lymph node metastasis of a high-grade neuroendocrine carcinoma. There was no evidence of pulmonary origin. PSA and NKX3.1 were negative, not excluding a prostatic origin. Tumor cells expressed cytokeratin AE1/AE3, synaptophysin, and chromogranin, with a Ki-67 index >80%. Six months separated the two resections and the patient remained asymptomatic nine months after surgery. Multidisciplinary review suggested either a neuroendocrine carcinoma of unknown primary or late neuroendocrine dedifferentiation from previously resected prostate adenocarcinoma. Given the indolent course, adjuvant chemotherapy was not initiated, and active surveillance was chosen. RESULTS Neuroendocrine carcinoma may rarely present as nodal metastases from an unknown primary. Neuroendocrine transformation of prostate adenocarcinoma has been described, usually in the setting of resistance to androgen-deprivation therapy. To our knowledge, an oligometastatic neuroendocrine disease occurring decades after prostate resection with an indolent course has not been previously reported. CONCLUSIONS This case highlights an exceptional indolent course of metastatic high-grade neuroendocrine carcinoma and underscores the need to consider prostatic origin despite negative markers. It supports cautious therapeutic individualization in patients with atypical disease behavior.

ABSTRACT. OBJECTIVE

Pelvic fractures in children are rare and most often result from high-energy trauma. Current classification systems, including the Tile classification, primarily focus on pelvic ring instability and apophyseal avulsion injuries. Isolated fractures of the iliac bone sparing the pelvic ring are rarely described in pediatric trauma literature and may therefore be overlooked. We report an unusual horizontal fracture of the iliac bone located between the anterior superior and anterior inferior iliac spines in an eight-year-old child. This fracture pattern was unexpected given the low-energy mechanism and is not clearly represented in existing classification systems.

METHODS

An eight-year-old girl presented to the emergency department with acute right pelvic pain and inability to bear weight following a low-energy incident at school. There was no history of direct impact. Examination revealed localized tenderness over the right iliac region. Hip range of motion was preserved but painful, particularly during flexion. No neurological or vascular deficits were identified. Standard anteroposterior pelvic radiographs were obtained. An apophyseal avulsion injury was initially considered; however, imaging findings were inconsistent with this diagnosis. In the absence of pelvic ring involvement and given the patient’s stable condition, conservative management was chosen. Follow-up was scheduled at one, two, and four weeks.

RESULTS

Radiographs demonstrated a non-displaced horizontal fracture of the right iliac bone between the anterior superior and anterior inferior iliac spines, without signs of apophyseal avulsion. Treatment was conservative and consisted of complete non-weight-bearing for a total duration of one month. Pain resolved rapidly. At four weeks, radiographs confirmed fracture union, and the patient had regained full, pain-free hip motion with a normal gait.

CONCLUSIONS

In our experience, this fracture pattern represents a distinct and under-recognized pediatric iliac injury. Awareness of this entity may prevent misdiagnosis and supports conservative treatment, which can lead to excellent functional outcomes.

ABSTRACT. Introduction: Carotid artery stenosis remains one of the leading causes of major stroke. Carotid endarterectomy (CEA) has proven effective in preventing major stroke. We are reporting the outcomes of CEA performed in our center. Materials and Methods: This was a retrospective case series of 120 patients who underwent CEA from the year 2020 until 2025. Patients having asymptomatic (≥60-99%) and symptomatic carotid artery stenosis (≥50-99%) were selected for the procedure. All patients received best medical treatment, which include antithrombotic medications, lipid lowering therapy, blood pressure management, diabetes mellitus management and lifestyle modifications especially smoking cessation. All the patients underwent CEA under loco-regional anaesthesia with continuous neurological control. No Shunt was done routinely. Preoperative, intraoperative, and postoperative data were collected and evaluated. Mortality, myocardial infarction, stroke, postoperative bleeding, surgical site infection and cranial nerve injury at 30 days were the outcomes investigated. We also evaluated restenosis after CEA. Results: Most patients in our series were males 70% (n = 84) compared to 30% (n = 36) females. There were more symptomatic patients (n = 86) than asymptomatic patients (n = 34). There was four 30-day mortality among the symptomatic patients, while there was no 30-day mortality in the asymptomatic patients. The 30-day myocardial infarction was 3% (n = 4). In this cohort, only two patients had 30-day stroke (2%), which were symptomatic patients. There were no cranial nerve injuries. Only one patient had postoperative bleeding which did not need any reintervention. Two surgical sites infections was noted on all patients. Five patients developed restenosis (4%), two of them had symptomatic restenosis which resulted in them being reoperated with an endovascular procedure. Conclusion: By sharing these outcomes data, hopefully it will create awareness among medical practitioners on the importance of early referral for carotid artery stenosis. Long term outcomes are very much needed.

ABSTRACT. We present the case of a 66-year-old man (history of hypertension, hyperlipidemia, chronic kidney disease and active smoking) with a saccular juxtarenal aortic aneurysm (48mm maximum diameter) treated with a fenestrated endograft (FEVAR) with 4 fenestrations in june 2020.

Good patency without endoleak (EL) at 1 month was seen. At 1 year, stable diameters, EL type II presumed.

After 2 years, the aneurysm growth to 55mm and arguments for type IIIa EL or IIIc/Ic from the LRA are seen on CT scan. A selective angiography followed with flaring of the stents in the LRA, RRA and SMA was performed. A cranial endoleak was seen on AP angiography, but not in lateral view, no clear entry was visualized.

Further growth towards 57mm was observed 6 months later, followed by a second relining (TC, SMA, RRA) with extra stents.

As this did not lead to resolution of the EL, the patient was referred to our hospital.

Seven CT’s and 2 relinings after the index FEVAR, patient underwent another relining without success. A focal fabric tear was suspected and open exploration was planned. After positioning of safety guidewires in the 4 bridging stents, a type IIIC EL from the LRA was observed. To obtain haemodynamic control, the fenestration was oversewn with pledgets under supra-celiac clamping time.

Postoperative occlusion of the LRA on duplex ultrasound was noted, further uneventful hospital stay.

CTA after 30 days showed an occluded LRA, diameter reduction of the aneurysm sack and small type 2 EL (lumbar) BUT an iatrogenic focal dissection at the level of the supra-celiac clamping site and bare stents.

CTA showed progressive diameter growth over time of the descending thoracic aorta post dissection (39mm-42mm-48mm). 22 months after the laparotomy, an additional TEVAR was performed.

The diameters remained stable 18 months later. A small type II endoleak (lumbar) was present.

ABSTRACT. OBJECTIVE

Traumatic arteriovenous fistulas are a rare complication of vascular trauma and are mainly reported as isolated case reports, making their management challenging. Most cases are secondary to iatrogenic injury or penetrating trauma, whereas blunt trauma is uncommon. We report a rare case of a post-traumatic arteriovenous fistula of the gracilis muscle following blunt trauma, managed with a multistage endovascular approach and long-term follow-up.

METHODS

A 27-year-old woman presented with a progressive pulsatile mass of the right medial thigh following a traumatic episode during pole dancing, involving a sudden and forceful grip using the thighs. Clinical examination revealed a palpable thrill. Imaging assessment included MRI and CT angiography to characterize the lesion and guide treatment. A stepwise endovascular strategy was performed using coil embolization of the arterial feeders through a contralateral femoral approach. Long-term clinical and imaging follow-up was conducted.

RESULTS

Initial embolization in 2016 targeted the deep femoral artery feeding the fistula, resulting in early reduction of lesion size. Persistent supply from the superficial femoral artery required a second embolization procedure in 2018. Following treatment, the mass became soft and non-pulsatile with symptomatic improvement.

The lesion remained stable for several years. In 2024, CT angiography demonstrated enlargement of the venous components with recurrence of symptoms. Residual arterial supply originated from the obturator artery and was not accessible to endovascular treatment, leading to surgical excision of the fistula with gracilis muscle resection. Postoperative recovery was uneventful, with complete symptom resolution.

CONCLUSIONS

Endovascular treatment represents an effective first-line therapeutic option for traumatic arteriovenous fistulas when endovascular access is technically achievable. However, complex lesions with progressive arterial recruitment may require staged procedures with surgery remaining a valuable complementary therapeutic option.

ABSTRACT. OBJECTIVE We are presenting the case of an 83 year old man, with a history of an aortobifemoral bypass, who developed an aneurysmatic dilatation on the left common and internal iliac artery. This was an incidental finding on an abdominal CT. The patient was asymptomatic at the time of the diagnosis. The aneurysmatic transformation of the iliac arteries develops in case of diseased iliac arteries with progression of the underlying atherosclerotic process, if there is persistent retrograde perfusion or in case of incomplete exclusion of aneurysmal segments during initial repair.

METHODS The treatment method is chosen carefully considering location of aneurysm, the size, comorbidities of the patient, risk for pelvic ischemic complications and the need for preserving the internal iliac artery. In this case we applied the banana technique, excluding the common iliac artery. Because of the diameter mismatch between distal internal iliac artery and the external iliac landing zone we decided to use two different stents: in the distal segment we placed a Gore Viabahn SX which was followed by a Gore Viabahn BX stentgraft.

RESULTS Successful exclusion of the aneurysmatic segments of the common and internal iliac arteries using the banana technique. We used a Viabahn SX stent (7x100mm) in the internal iliac artery, extending into the external iliac artery using the Viabahn BX stent (8x79mm). The patient left the hospital on postoperative day 2. He developed gluteal soreness and ecchymosis postoperatively with complete resolution in a few weeks. There were no major postoperative complications.

CONCLUSIONS Successful endovascular treatment of the aneurysmatic dilatation of the common and internal iliac artery, using the banana technique.

ABSTRACT. OBJECTIVE: While endovascular repair is widely used for descending thoracic aortic aneurysms, a subset of patients remains unsuitable for this approach due to anatomical or pathological constraints. This study reports early outcomes of open surgical repair performed over one year in patients not eligible for endovascular treatment. METHODS: Four patients with descending thoracic aortic aneurysms underwent open repair via left thoracotomy. Indications included one saccular aneurysm (25%), two fusiform aneurysms (50%), including one patient with Loeys–Dietz syndrome (25%), and one inflammatory/infected aortitis (25%). Surgical exposure was achieved through the fourth intercostal space in one patient (25%), the fourth and seventh intercostal spaces in two patients (50%), and the fourth and eighth intercostal spaces in one patient (25%). All procedures were performed under cardiopulmonary bypass without cardiac arrest. Three patients (75%) underwent replacement with a synthetic Dacron graft, and one patient (25%) received a cryopreserved arterial homograft. Mean operative time was 4 hours. RESULTS: Proximal aortic clamping was achieved between the left common carotid and left subclavian arteries in three patients (75%) and distal to the left subclavian artery in one patient (25%). Intercostal artery reimplantation was performed in one patient (25%). There were no cases of stroke or spinal cord ischemia. One patient (25%) sustained left recurrent laryngeal nerve injury in the setting of infection, resulting in non-disabling hoarseness. All patients required one night in intensive care (100%) and were discharged home within 7 days. One patient (25%) required redo thoracotomy for pleural drainage at one-month follow-up. CONCLUSIONS: Open surgical repair of descending thoracic aortic aneurysms remains a safe and effective option for patients unsuitable for endovascular repair, with low neurological morbidity (0%) and favorable early outcomes. In the short term, all patients had an uneventful clinical course.

ABSTRACT. OBJECTIVE Aortic aneurysms can be fatal if left untreated. Few studies have investigated the outcomes and risks of open aortic repair (OSR) in solid organ transplantees. Owing to lack of consensus, thresholds for treatment in this population along with the choice between EVAR and OSR varies by clinician. This retrospective observational study aims to provide data on outcomes in transplanted patients, specifically after OSR.

METHODS We used data from a single large center in Belgium. Patients having a history of solid organ transplant and immunosuppression at the time of OSR were included. We used data from medical records to determine the outcomes. The inclusion period was from 01-01-2016 to 12-11-2024 with 451 patients being screened. We performed a descriptive analysis due to a small sample size. The primary outcome was 30-day mortality. We also evaluated known complications of OSR, including graft infection, acute kidney injury, and acute myocardial infarction; additional parameters included transplant failure, length of hospital stay, and reintervention.

RESULTS A total of 8 patients were included in the study, 4 heart, 3 lung and 1 combined liver–kidney transplant recipients. Indications for OSR were aortic occlusion/stenosis in 5 (62,5%) patients and aneurysm in 3 (37,5%) patients. 1 (12,5%) patient died within 30 days of the operation. Complications reported were acute kidney injury in 5 (62,5%) patients, aortic graft infection in 1 (12,5%) patient with secondary pancreatitis, reoperation in 1 (12,5%) patient. No acute myocardial infarction or transplant failure were reported.

CONCLUSION Our data suggests a potential increased risk of certain complications, including acute kidney injury and aortic graft infection in transplantees when compared to the general population, although most patients had favourable long-term outcomes following OSR. Limitations of the study are a retrospective design, non-randomization, and small sample size. This limits the strength of our conclusions, and further study is necessary.

ABSTRACT. OBJECTIVE To report the feasibility and outcomes of a fully endovascular strategy combining thoracic endovascular aortic repair (TEVAR) with distal fenestration and adaptive intraoperative techniques for the treatment of a chronic type B aortic dissection with rapid progressive related aneurysm in an elderly patient. METHODS An 86-year-old woman developed a type B aortic dissection during cardiopulmonary bypass for ascending aorta and hemiarch replacement. Follow-up computed tomography demonstrated a descending thoracic aneurysm with progressive false lumen enlargement and persistent back pain. After delayed consent, endovascular repair was performed 119 days after onset. The procedure included spinal cord drainage, image fusion guidance, intentional distal fenestration of the dissection flap to create distal sealing andTEVAR with rapid pacing. Intraoperative complications included acute occlusion of the left renal artery and superior mesenteric artery, managed with the STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique and followed by selective mesenteric artery stenting. RESULTS Final angiography demonstrated complete remodeling of the aorta with exclusion of the aneurysm and restored perfusion of all four visceral arteries. Postoperatively, the patient presented abdominal pain. An early imaging was performed and revealed a contained contrast extravasation near the renal arteries, which was managed conservatively. Serial computed tomography showed no progression at 4 hours, followed by complete thrombosis of the pseudoaneurysm at 48 hours . The patient was discharged home on postoperative day 5, asymptomatic. A 6-week imaging follow-up was scheduled. CONCLUSIONS This case highlights the importance of meticulous preoperative planning, distal fenestration to improve sealing, and real-time adaptability during endovascular repair of chronic type B aortic dissection. Conservative management of selected postoperative complications may be safe in stable patients and can reduce procedural morbidity.

ABSTRACT. Objective The primary objective was the complete exclusion of bilateral primitive iliac artery aneurysms involving the iliac bifurcation in a 58-year-old male. The surgical goal focused on the successful exclusion of the aneurysmal sacs while preserving both internal iliac arteries.

Background Isolated iliac artery aneurysms are often asymptomatic but carry a significant risk of rupture. Traditional open surgery involves extensive pelvic dissection with higher morbidity. Endovascular Aneurysm Repair (EVAR) using Iliac Branch Devices (IBD) has emerged as a less invasive alternative, specifically designed to exclude aneurysmal sacs while preserving of the internal iliac arteries.

Case Report A 58-year-old male smoker with hypertension presented with abdominal and back pain. CT angiography revealed bilateral primitive iliac aneurysms (right 4 cm, left 4.5 cm) involving the bifurcations. An endovascular approach was performed using an aorto-bi-iliac main body and bilateral IBDs. During the procedure, a deployment failure occurred at the right iliac limb, necessitating a rescue femoro-femoral crossover bypass to ensure distal limb perfusion. Postoperative CT angiography at three days and 3D reconstruction at three months confirmed successful aneurysm exclusion. Type II endoleak was further identified with a Watch and Wait management and regular CT angiography surveillance.

Conclusion Endovascular repair with IBDs is a viable technique for treating complex bilateral iliac aneurysms while preserving pelvic circulation. While EVAR offers reduced operative time and improved perioperative survival compared to open surgery, clinicians must be prepared for intraoperative technical challenges that may require secondary surgical revascularization.

ABSTRACT. Objective A 66-year-old man presented with acute chest discomfort and limb paresthesia. His history included a Bentall procedure for aortic valve insufficiency and ascending aortic dilatation. CT angiography showed progressive aortic arch dilatation and a non-A-non-B aortic dissection extending toward the right femoral artery. A staged treatment strategy was planned, consisting of Frozen Elephant Trunk (FET) repair followed by TEVAR and FEVAR. The patient underwent redo aortic arch repair with FET implantation. Postoperatively, acute right lower limb ischemia developed. CT angiography revealed erroneous positioning of the FET prosthesis in the false lumen, causing true lumen compression and thrombosis. Open surgical thrombectomy of the right external iliac and femoral arteries and resection of the dissection flap in the common femoral artery restored perfusion. On postoperative day one, acute ischemia of the left lower limb occurred due to progressive true lumen collapse with false lumen perfusion. Methods Through open femoral artery access, controlled endovascular fenestration of the dissection flap at the infrarenal aortic level was performed using a steerable sheath and cardiac transseptal needle. After fenestration, a through-and-through wire was created from the right to the left groin. Balloon angioplasty was performed to widen the fenestration and establish communication between true and false lumen. Results Fenestration resulted in restoration of antegrade flow to the true lumen and bilateral iliac and femoral arteries, confirmed by angiography. Clinical signs of limb ischemia resolved promptly without additional stenting or surgical bypass. Stent placement was avoided to prevent compromising future FEVAR. No complications occurred, and no recurrent malperfusion was observed during early follow-up. Conclusions In limb-threatening ischemia due to false lumen dominance after FET implantation, endovascular fenestration of the dissection flap is an effective and reproducible bailout technique, allowing rapid restoration of distal perfusion while avoiding extensive reintervention. Cardiac transseptal needles may be used when dedicated re-entry catheters are unavailable.

ABSTRACT. Objective Abdominal aortic coarctation is a rare condition, accounting for a small proportion of all aortic coarctations, with infrarenal involvement being particularly uncommon. Clinical presentation is variable, most commonly including refractory hypertension and bilateral claudication. Therefore, diagnosis is often incidental or delayed due to nonspecific symptoms. We present the case of a 76-year-old woman who was followed at our outpatient clinic for infrarenal aortic coarctation. Method The patient was referred to our department in 2016 for an incidentally discovered infrarenal aortic coarctation. At that time, she was asymptomatic and managed conservatively with imaging surveillance. After long-term follow-up, the patient developed progressive bilateral claudication. Computed tomography demonstrated progression to near-occlusion of the infrarenal aorta. Due to extensive calcification, open surgical repair with an aorto-aortic interposition graft was performed. Results The postoperative course was uncomplicated, and the patient experienced complete resolution of symptoms. Several surgical techniques for abdominal aortic coarctation have been described in the literature, including thoracoabdominal bypass grafting, aorto-aortic interposition grafting, and patch angioplasty. Due to the rarity of this pathology, no comparative studies evaluating long-term outcomes in adult patients are available. Consequently, the choice of treatment should be individualized, taking into account aortic anatomy, vessel wall quality, and involvement of visceral arteries. The aetiology of abdominal aortic coarctation remains uncertain and may be congenital or acquired. Conclusion Infrarenal aortic coarctation is a rare condition with a variable and often indolent clinical course, which may lead to delayed diagnosis. Even when initially asymptomatic, regular follow-up is crucial, as disease progression may necessitate intervention. Surgical repair provides excellent symptomatic relief, and the choice of technique should be tailored to individual anatomical and pathological characteristics.

ABSTRACT. OBJECTIVE The shift towards competency-based surgical training requires objective tools that reliably assess technical performance and progression. In metabolic bariatric surgery (MBS), such tools remain limited. This study evaluated whether automated video-based performance analytics can objectively track trainee progression during laparoscopic primary Roux-en-Y gastric bypass (RYGB), a key procedure in MBS training.

METHODS A prospective observational study was conducted at a high-volume bariatric center. Four surgical trainees with varying experience levels were included. All laparoscopic primary RYGB procedures performed over a seven-month period were video-recorded using the Touch Surgery™ Video platform. Objective performance metrics were automatically generated with Touch Surgery™ Performance Insights and compared to a departmental benchmark case. Workflow adherence, total operative time, and phase-specific timing were analyzed. Multivariate linear regression and cumulative sum (CUSUM) analyses were applied, adjusting for patient-related variables including body mass index, sex, and comorbidities.

RESULTS Eighty-two laparoscopic primary RYGB procedures were analyzed. Workflow adherence ranged from 65% to 89% among trainees. Mean operative time exceeded benchmark values but decreased progressively with case volume. One trainee demonstrated near-benchmark performance, consistent with advanced training. Another showed significant operative time improvement over successive cases (p < 0.05). A third trainee displayed a clear learning breakpoint in biliopancreatic limb measurement after 12 procedures (p < 0.001). CUSUM analysis revealed distinct learning curves and phase-specific variability, enabling identification of performance milestones.

CONCLUSIONS Video-based analytics offer an effective, objective method for evaluating technical progression in MBS training. By turning surgical performance into measurable data, this approach helps identify strengths, pinpoint learning needs, and support fair, structured feedback. These findings support the integration of standardized video-based assessment tools in MBS curricula and could make surgical education more transparent, tailored, and effective.

ABSTRACT. Background Upper gastrointestinal endoscopy with biopsy has its clear limitations in populations-level screening for esophageal cancer. Consequently, novel non-invasive diagnostics are increasingly explored. This phase IIa diagnostic study aimed to characterize the breath-derived oncometabolic profile of esophageal cancer patients using a higly-specific fully portable electronic nose (E-nose) platform.

Methods The study population included healthy volunteers (n=37) and patients with esophageal cancer (n=33) recruited between May 2025 and October 2025. Exhaled alveolar breath samples were collected and analyzed using a next-generation metal-oxide E-nose, quantifying multiple gastroesophageal cancer–associated volatile biomarkers across five catalytic sensor arrays. Differential expression of oncometabolites between esophageal cancer patients and healthy controls was assessed using volcano plot analysis with a false-discovery rate correction. Principal component analysis (k=2) and unsupervised hierarchical clustering with heat-map visualization were performed to identify distinct metabolic clusters.

Results Among the esophageal cancer cohort, the majority presented with locally advanced disease stages (n=25, 75.8%), adenocarcinoma (n=27, 81.8%) and poorly differentiated tumors (n=18, 54.5%). The volcano plot analysis identified the oncometabolites with the most significant differential expression between cancer patients and healthy individuals per sensor: 2-pentanone (log-fold −5.03, p<0.001), acetone (4.99, p<0.001), toluene (4.04, p<0.001), butane (−3.89, p<0.001), and 2-propanol (−3.87, p<0.001). Principal component analysis revealed two clearly separated clusters corresponding to healthy controls and esophageal cancer patients. Heat-map analysis further demonstrated distinct oncometabolite expression patterns differentiating these similar groups (Figure 1).

Conclusion E-nose technology effectively identified a discriminative oncometabolic signature in patients with esophageal cancer, with 2-pentanone, acetone, toluene, butane, and 2-propanol emerging as the most significantly altered metabolites. The distinct metabolic profile observed in esophageal cancer supports the potential clinical utility of breath-based diagnostics and provides a foundation for future research into metabolic targets and biology-driven disease stratification.

ABSTRACT. Objective Endovascular surgery is a high-risk specialty where safety protocols are vital to prevent adverse events. While WHO Surgical Safety Checklist (SSC) implementation showed significantly reduced overall surgical morbidity and mortality, more recent studies have shown mixed results. This study aims to observe real-world adherence to the time‐out phase of the WHO SSC in a hybrid Operating Room (OR) and to evaluate the Checklist Performance Observation for ImprovemeNT (CheckPOINT) tool.

Methods This single-centre retrospective observational study of prospectively collected data included endovascular procedures performed in a hybrid OR between May 2021 and December 2022. In October 2021, paper SSCs were replaced with electronic SSCs. Procedures were recorded using the OR Black Box (Surgical Safety Technologies Inc., Toronto, Canada). Time-out evaluation of recorded procedures was performed using the CheckPOINT tool.

Results Time-out was initiated in 87.7% (n = 186/212) of all procedures. Average overall reported completion was 95.5% with a median of 15 completed items. Average overall observed completion was 46.8% with a median of 7 items completed. Observed adherence was significantly lower than reported adherence for all but one item, “Patient Name”. Experienced surgeons were significantly less likely to initiate (p = 0.033) and thoroughly complete (p < 0.001) the checklist. CheckPOINT engagement scored significantly lower than adherence, communication effectiveness and attitude.

Conclusion Video-based observation reveals significant discrepancies between observed and reported SSC adherence. These results highlight the need for improved SSC assessment and implementation, and suggest that combining reliable tools with video recording can enable data-driven quality improvement initiatives.

ABSTRACT. Background The Breakthrough Improvement Collaborative for Rectal Cancer (BIC4ReCa) was established to assess variation in rectal cancer care across Belgian hospitals and promote adherence to evidence-based practice. Methods A retrospective multicenter analysis was conducted in 22 hospitals (2020–2024). Each hospital contributed 20 patients undergoing curative-intent rectal cancer surgery. Quality Indicators (QIs) were defined through literature review and Delphi consensus. Outcomes were analyzed at aggregated and hospital levels. Results A total of 430 patients were included; 67.9% were male, with a mean age of 68.8 ± 12.0 years. Preoperative rectal MRI and Thoracoabdominal CT were performed in 94.2% and 97.3% respectively. Clinically, 58.6% was staged cT3 and 56.5% had node-positive disease. Substantial variation in perioperative management was observed within and between hospitals. Adherence to the guidelines was mapped for measured QIs (Figure 1). Lowest overall adherence rates was seen for oral antibiotic administration (13.0%), avoidance of drain placement (13.0%), postoperative LARS evaluation (24.5%), and early urinary catheter removal (43.7%). Highest adherence (>90%) was observed for preoperative MRI, CT, and colonoscopy. Qis with large inter-hospital variation were mechanical bowel preparation (74%), stoma site marking (63.5%), avoidance of prolonged nasogastric tube use (75.6%) and IV antibiotic prophylaxis at induction (76.5%). Postoperative ICU or medium-care admission occurred in 37.2% (range 0–100%). Median length of stay was 7 days (IQR 5–12). In-hospital complications occurred in 46.7: prolonged ileus (>4 days, 17.0%), stoma-related complications (14.1%) and urinary retention (10.0%). Ninety-day readmission, reintervention, and anastomotic leakage rates were 21.1%, 19.5%, and 17.4%, respectively, with 90-day mortality 2.8% (Table 1). Conclusions Large within-and between hospital variation was observed in surgical practice, perioperative management, and short-term outcomes of rectal cancer care across Belgian hospitals. While adherence to some evidence-based QIs was high, others remained low, highlighting the need for targeted quality improvement and further standardization of rectal cancer care.

ABSTRACT. Objective: Adjunctive strategies including preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA) injections may be required in patients with large incisional hernias (LIH) and loss of domain (LOD). It remains unclear whether the need for such prehabilitation can be predicted. This study examines the predictive value of established CT-based indices in patients with LIH and LOD.

Methods: A retrospective study was conducted at a tertiary referral center. Inclusion criteria encompassed midline incisional hernias wider than 10 cm on an available pre-treatment CT scan. Patient and hernia characteristics, as well as Tanaka’s index, rectus-to-defect ratio (RDR), component separation index (CSI), Sabbagh’s index, and Reims ratios 1 and 2 were assessed. Outcomes were compared for patients with versus without the need for BTA/PPP. The predictive value of each index was analyzed using univariate binary logistic regression and ROC analysis.

Results: All CT indices were significantly associated with the need for preoperative treatment (p < 0.001). Reims ratio 1 (AUC 0.849) and Sabbagh’s index (AUC 0.847) showed the highest discriminative power, closely followed by Reims ratio 2 (AUC 0.819) and Tanaka’s index (AUC 0.817). The CSI (AUC 0.681) and RDR (AUC 0.320) proved less adequate. Established cut-off values for Tanaka’s index, Sabbagh’s index and Reims ratios 1 and 2 are 17,5%, 15%, 25% and 25% respectively.

Conclusions: Reims ratio 1 and Sabbagh’s index seem the strongest predictors for preoperative preparation using BTA/PPP. Cut-off values may serve as the first step towards integrating CT-indices in routine clinical decision making.

ABSTRACT. The AURA10 camera is a mobile PET/CT scanner (XEOS, Belgium) designed to acquire high-resolution images of surgical specimens directly in the operating room. Patients undergoing intra-operative PET/CT receive a low activity of a PET tracer shortly before surgery. We report our initial experience with this novel technique across a broad range of clinical indications. A try-out with the device was initiated at Maria Middelares Hospital in Ghent to explore potential clinical applications. This was a non-sponsored prospective study, approved by the local ethics committee and registered as NCT06835426. Inclusion criteria consisted of patients scheduled for an intervention for metabolically active disease, including a wide spectrum of tumours requiring surgery or biopsy. Approximately one hour prior to resection, a small dose of 18F-FDG was administered, or alternatively 18F-PSMA or 18F-Choline in cases of prostate cancer or parathyroid adenoma. Immediately after resection, the specimen was scanned in the operating room for 12 minutes. PET/CT images were reviewed by the surgeon and the specimen was subsequently sent for pathological examination.

In total, 94 intra-operative PET/CT procedures were performed: breast cancer (33), prostate cancer (24), thyroid cancer (16), lymph node biopsy (8), bone biopsy (2), parathyroid adenoma (3), skin cancer (4), bladder and renal cancer (3), and liver cancer (1). The added value of the technique was most pronounced in breast cancer, particularly for assessment of surgical margins, and in patients with relapsed thyroid carcinoma.

An illustrative case involves a 75-year-old woman with residual cervical lymph node metastases following total thyroidectomy and bilateral lymphadenectomy for papillary thyroid carcinoma. Intra-operative PET/CT assisted a subsequent lateral neck dissection, ensuring complete removal of metabolically active lymph nodes.

Overall, intra-operative PET/CT imaging showed good concordance with pathology, especially in breast and thyroid cancer, and proved helpful in confirming complete resection of suspicious lymph nodes in carefully selected surgical oncology settings worldwide today.

ABSTRACT. Objective: Healthcare professional wellbeing is an essential but underappreciated aspect of endovascular surgery, a discipline characterized by high cognitive, physical, and psychosocial demands. Despite growing attention to work-related wellbeing, little is known about intraprocedural dynamics within multidisciplinary teams. This study examines fluctuations in mood and fatigue among team members in the hybrid operating room during elective endovascular procedures.

Methods: In this single-centre prospective observational cohort study, surgeons, anesthesiologists, and scrub nurses filled in questionnaires before and after endovascular procedures. These questionnaires assessed mood, fatigue, and factors such as perceptions of transformational surgical leadership, procedure duration, day of the week, and self- and team-evaluations.

Results: During procedures, fatigue decreased significantly while team members’ mood generally improved, particularly among the primary surgeon. Transformational leadership behaviour by the primary surgeon correlated positively with improved mood in all team members. Procedure duration and day of the week did not significantly influence mood. Self- and team-evaluations of performance correlated positively with mood.

Conclusion: This study demonstrates that team members’ well-being fluctuates during endovascular procedures and is most influenced by leadership style and perceptions of self- and team performance. Transformational leadership and positive team cohesion most strongly promote improved mood, highlighting the importance of strong leadership in the operating room. These findings underscore that psychosocial factors and team dynamics have an important impact on wellbeing. Further research into leadership and cohesion in operating team dynamics could help inform interventions that support more sustainable environments for wellbeing in the operating room.

ABSTRACT. OBJECTIVE Laparoscopic hiatal hernia repair is associated with high recurrence rates. The PRIME study, which investigated non-absorbable synthetic mesh reinforcement of posterior crural reconstruction, demonstrated a similar recurrence rate after 6 months compared to primary crural reconstruction (19.4% vs. 11.4%, p=0.370). Research into redo procedures shows that recurrences usually occur on the left anterior side of the oesophageal hiatus. This study investigates the effect of circular bio-absorbable mesh reinforcement in hiatal hernia repair. METHODS This double-blind trial, conducted in three centers, included adult patients with a proven hiatal hernia (Skinner type II-IV). Patients were randomized for laparoscopic crural reconstruction with or without circular, bio-absorbable mesh reinforcement. The primary outcome was recurrence of hiatal hernia after one year. Secondary outcome measures were clinical symptoms of recurrence, postoperative dysphagia, use of acid-suppressing medication, and patient satisfaction, collected via questionnaires completed preoperatively and at 3, 12, and up to 60 months postoperatively. RESULTS From 2019 to 2024, 223 patients (n=113 circular, bio-absorbable mesh vs. n=110 primary crural reconstruction) were included, with 93.3% objective follow-up available after one year. The recurrence rate was significantly lower in the mesh group after one year (n=37 [35.2%] vs. n=21 [20.4%], OR=0.471, 95% CI=0.252-0.879, p=0.018). There was no difference in the number of redo procedures performed within the first year (0 vs. 5 [4.7%], p=0.060). Both groups showed comparable improvements in symptom scores postoperatively. Quality of life was higher after circular, bio-absorbable mesh reinforcement. CONCLUSIONS Circular, bio-absorbable mesh reinforcement significantly reduces the recurrence rate one year after hiatal hernia repair. Symptom scores are comparable, while quality of life is higher after circular mesh repair compared to primary crural reconstruction.

ABSTRACT. Background For nearly four decades, surgical smoke has raised concerns regarding a possible association with lung cancer in operating room staff. Various factors, including the type of surgical instrument and the nature of the dissected tissues, influence the composition of this smoke and generate biological by-products with variable toxicity. Methods A systematic review was conducted in PubMed and Google Scholar up to January 2024, following PRISMA guidelines. Studies were included if they evaluated the chemical composition or particle size of surgical smoke generated during procedures on human tissues, or if they investigated its mutagenic effects on human cells; animal studies, opinion papers and conference abstracts were excluded. Results Seventeen studies met the inclusion criteria: nine on chemical composition, five on particle size and three on mutagenicity. Surgical smoke contained several potentially carcinogenic compounds, such as benzene and formaldehyde, with particles small enough to be inhaled and reach the pulmonary alveolar region; smoke originating from adipose tissue appeared more harmful than that from lean tissue, and mutagenic and cytotoxic effects were demonstrated in breast tissue models exposed to electrocautery smoke. Conclusions This systematic review indirectly assesses the potential carcinogenicity of surgical smoke for operating room staff by analysing particle size, chemical composition and mutagenic potential according to the type of human tissue dissected and the instruments used. The findings suggest that specialties involving frequent dissection of adipose tissue, such as plastic surgery and oncologic breast surgery, may be particularly at risk, although no definitive causal link with lung cancer has yet been established and long-term epidemiological data are lacking.

ABSTRACT. Background: For treatment of primary ventral hernias larger than 1 cm a mesh-based repair is recommended by the EHS guidelines and an extraperitoneal mesh placement is favoured. Most meshes used for abdominal hernia repair, based on polymeric textile, are invisible to conventional imaging techniques. A novel method has been developed in which iron oxide particles are incorporated into meshes, making them visible on magnetic resonance imaging (MRI). We have used this technology previously to study mesh shrinkage when the mesh was placed in the intraperitoneal and retro-muscular position.

Objective: Hernia recurrence may be linked to mesh shrinkage. As the amount of mesh shrinkage might affect the degree of mesh overlap achieved during hernia repair. The anatomical location of the implanted mesh is thought to be a key determinant of mesh behaviour. The aim of the study is to assess the mesh shrinkage by means of MRI visualization using an iron oxide loaded polyvinylidene fuoride (PVDF) mesh after robot assisted laparoscopic preperitoneal ventral hernia repair.

Methods: A prospective observational cohort study was conducted in patients with a midline ventral hernia undergoing robot-assisted laparoscopic preperitoneal mesh repair using an iron oxide loaded PVDF mesh. A total of 20 patients were included. MRI was used to measure the mesh surface area at 1 month and 13 months postoperatively. The primary outcome was the percentage of mesh surface shrinkage between 1 and 13 months. Secondary outcomes included changes in mesh width and length between implantation surface size, surface at 1m and at 13m, as well as patient-reported quality of life measured using the European Hernia Society Quality of Life (EuraHS-QoL) score.

Results: The last patient will return for follow-up shortly. The results will be available by the time of the presentation.

ABSTRACT. BACKGROUND In Belgium, surgical procedures are documented in electronic health records, while reimbursement, hospital financing, and reporting depend on separate coding systems such as the RIZIV-INAMI nomenclature and ICD-10-PCS. This fragmentation limits reuse of clinical data and creates administrative inefficiency. The International Classification of Health Interventions (ICHI) is a World Health Organization standard designed to support comparable intervention statistics and health system management. OBJECTIVE To assess whether SNOMED Clinical Terms procedure concepts can be reliably mapped to ICHI, enabling reuse of surgical documentation for standardized coding and reporting. METHODS A unidirectional mapping study was conducted on 2,528 SNOMED CT procedure concepts derived from a legacy procedure dataset historically linked to ICHI development. Candidate mappings to ICHI Stem codes and Inclusion terms were generated using automated lexical search and validated through structured semantic expert review. Mappings were classified as exact, narrow-to-broad, broad-to-narrow, partial, or unmatched. RESULTS A total of 1,907 procedures (75.4%) were successfully mapped to ICHI. Among these, 1,370 mappings were exact or narrow-to-broad, supporting automated conversion of clinical procedure documentation into ICHI codes. Partial matches were limited (98 procedures), and 87.5% of these could be resolved through post-coordination. CONCLUSIONS Most surgical procedures documented in SNOMED Clinical Terms can be consistently represented in ICHI. This provides a practical pathway to connect clinical documentation with standardized reporting and future financing models, reducing duplication and supporting transparent, interoperable coding in Belgium.

ABSTRACT. OBJECTIVE: Anastomotic leakage occurs in 8-20% of patients undergoing esophagectomy and is closely associated with impaired tissue oxygenation. This study evaluates the use of real-time spectral imaging for intraoperative assessment of gastric graft viability during laparoscopic esophagectomy.

METHODS: Intraoperative spectral imaging was performed in 33 patients undergoing Ivor–Lewis esophagectomy using a video-rate snapshot camera operating in the 460–600 nm range. The surgeon marked the chosen anastomotic site, and a well-perfused region located 2–3 cm proximal to the pylorus. In addition, a small piece of tissue excised from the proximal stomach served as an ischemic control. A deep learning model was applied to estimate tissue oxygen saturation in the marked regions of the gastric graft prior to anastomosis. Spectral imaging-derived oxygenation measurements were analyzed in relation to local capillary lactate levels as a metabolic reference for tissue perfusion and viability.

RESULTS: Spectral imaging enabled clear differentiation between well-perfused and ischemic tissue, with significantly lower tissue oxygen saturation values observed in ischemic regions (median 69.4% vs 30.9%, p < 10⁻⁸). A binary classifier based on tissue oxygen saturation achieved an area under the curve of 0.97 at a threshold of 51.50%. Tissue oxygen saturation demonstrated a strong negative correlation with local capillary lactate levels (r = −0.72, p < 10⁻¹³), supporting its physiological relevance. In representative cases, spectral imaging identified proximal ischemic boundaries in grafts that later developed anastomotic leakage, indicating sensitivity to early hypoxic changes.

CONCLUSION: Real-time spectral imaging provides a contrast-free, quantitative method to assess tissue oxygenation during esophagectomy. Its ability to detect hypoxia and its strong correlation with metabolic markers highlight its potential value for intraoperative guidance in selecting a well-perfused anastomosis site.

ABSTRACT. Objective Chronic postoperative inguinal pain (CPIP) remains a relevant long-term complication after groin hernia repair; we aimed to evaluate potential preoperative predictors of CPIP at 1 year.

Methods: Groin hernia patients operated between Jan-2018 and Oct-2024 were included. The dataset comprised of pseudonymized patient demographics, operative characteristics, and relevant patient-reported outcome measures (PROMs) collected preoperatively and up to 5 years postoperatively. CPIP was defined as a numeric rating scale (NRS) score ≥4 on at least one operated side at 1-year. Demographics, surgical details and preoperative PROMs were compared between patient with and without CPIP. A multivariable ridge logistic regression model was developed using patient data. Missing data were handled using multiple imputation (m=20). Internal validation was performed using 5-fold cross-validation, with assessment of discrimination, calibration, and decision curve analysis. Results were reported with 95% confidence intervals (CIs) and significance level was set at 0.05.

Results: Overall, 1,509 patients with available pain score at 1-year were included. The mean age of participants was 64.43±12.49 years, and males were predominant (93.6%). Ninety-nine patients (6.6%) met the definition of CPIP. CPIP was associated with higher preoperative pain score (p<0.001), more positive symptoms on Douleur Neuropathique 4 questionnaire (p<0.001), presence of other preoperative pain (p<0.001), higher anxiety (p<0.001) and depression score (p=0.001) according to Hospital Anxiety and Depression Scale (HADS), and lower preoperative satisfaction score (p=0.001). The prediction model including the aforementioned PROMs along with age, sex, body mass index, laterality, recurrence status, and ASA classification demonstrated moderate discrimination (area under the curve 0.71, 95%CI 0.66–0.75), acceptable calibration, and net clinical benefit across clinically relevant risk thresholds.

Conclusion: Preoperative PROMs – particularly presence of other types of pain, pain intensity, neuropathic symptoms, and psychological distress – were consistently associated with CPIP and contributed to a multivariable prediction model with moderate performance. External validation is required before clinical implementation.

ABSTRACT. OBJECTIVE Ehlers-Danlos syndrome (EDS) is a heterogeneous group of inherited connective tissue disorders characterized by defects in collagen synthesis, leading to tissue fragility. The vascular subtype (vEDS) is the most severe form with colonic perforation being a well-documented but rare manifestation, often occurring spontaneously.

METHODS A 19-year-old male with vEDS presented at the emergency department with abdominal pain and distension. Initial abdominal CT suggested mechanical obstruction at the sigmoid colon, suspicious for volvulus. He underwent endoscopic decompression and rectal cannula placement at a peripheral center. Clinical and biochemical deterioration with fever prompted repeat imaging, revealing further colonic dilatation with ascites leading to referral to a tertiary center. Repeat colonoscopy demonstrated a sigmoid ulcer with colonic perforation. The patient underwent urgent laparoscopic exploration with primary closure of the perforation and creation of a protective loop colostomy.

RESULTS Three months after discharge, the patient represented with omental evisceration through the colostomy after vomiting, requiring urgent laparoscopic repair by primary closure of the perforation at the colostomy-site. A laparoscopic total colectomy with ileostomy was performed two months later. The postoperative course was complicated by haemorrhagic shock due to bleeding from the mesorectum and left mesocolon requiring revision laparoscopy and intensive care admission. Subsequent ileostomy reversal using a SILS approach with ileorectal anastomosis was performed several weeks later. Bleeding at the previous ileostomy site led to small-bowel evisceration, requiring urgent surgical revision with primary repair. The patient was discharged after 2 weeks.

CONCLUSION Patients with vEDS carry a significantly higher surgical risk due to tissue fragility, both intraoperatively and postoperatively. Management should occur at a tertiary care center. Although data are limited to small case series, total colectomy with ileorectal anastomosis or end ileostomy is preferred to reduce the risk of recurrent perforation. Careful preoperative counselling is essential to discuss the increased operative risks and potential complications.

ABSTRACT. BACKGROUND Gastro-gastric fistula is a rare late complication after Roux-en-Y gastric bypass, associated with incomplete pouch separation, staple-line leaks, marginal ulcers and ischemia or tension at the gastrojejunostomy. Previous open bariatric surgery increases technical complexity due to adhesions and altered anatomy, making management of complications challenging and requiring meticulous operative planning.

CASE PRESENTATION A 58-year-old woman with a body mass index (BMI) of 37.5 kg/m² presented with new-onset reflux, regurgitation, epigastric discomfort and 10-kg weight regain, with postprandially worsening of symptoms. Her surgical abdominal history included vertical banded gastroplasty in 1999, open retrocolic retrogastric Roux-en-Y gastric bypass in 2012, childhood laparotomy for liver biopsy and laparoscopic cholecystectomy. Physical examination revealed right hypochondrial tenderness. Upper gastrointestinal contrast study and gastroscopy demonstrated a chronic gastro-gastric fistula communicating with the excluded stomach, caused by erosion of a retained gastric outlet band. Endoscopic management was not feasible due to incomplete removability of the foreign material. A robotic-assisted revisional procedure was performed, including extensive adhesiolysis, partial gastrectomy with removal of the eroded band and primary fistula closure while preserving the existing gastrojejunostomy. Postoperative contrast study on day 2 showed no leak and good passage and the patient was discharged on day 3 postoperatively. A superficial extraction site wound infection occurred at 2 weeks and resolved with local care. At 4 weeks, BMI had decreased to 35 kg/m², reflux symptoms had resolved and no dysphagia was reported.

CONCLUSION Gastro-gastric fistula should be considered in patients with recurrent reflux and weight regain after conversion from vertical banded gastroplasty to Roux-en-Y gastric bypass, particularly when foreign material is retained. Durable symptom resolution requires removal of the underlying pathology rather than fistula closure alone. In complex revisional bariatric surgery, the robotic platform offers advantages in visualization, precision and tissue preservation, enabling safe management while maintaining a functional gastrojejunostomy and favorable postoperative outcomes.

ABSTRACT. OBJECTIVE

Ventral mesh rectopexy (VMR) is a surgical treatment for rectal prolaps. Reported recurrence rates following surgical repair vary depending on the operative technique employed. For VMR, recurrence rates range from 2.8% to 12%. A recently published multicentre study demonstrated substantial inter-institutional variability in perioperative management and surgical technique for VMR, underscoring a lack of procedural standardization. This may adversely affect recurrence rates and patient outcomes. Recurrence, as well as complications such as mesh erosion or infection, may necessitate revision surgery. This case illustrates the technical challenges of redo VMR for recurrent rectal prolapse.

METHODS

We present a robotic revision VMR in a patient with a symptomatic rectocele and a history of prior rectopexy and Delorme procedure. Clinical evaluation demonstrated a mucosal prolapse. MRI defecography revealed rectal prolaps with associated intussusception. Management decisions, including dissection planes and mesh placement, were made collaboratively between trainer and trainee. Inspection revealed detachment of the mesh from the sacral promontory. Dens adhesions were encountered, with omentum adherent to the mesh. Non-absorbable Ethibond sutures from the prior repair were identified and were associated with significant adhesions, contributing to erosion. During mesh removal, this erosion resulted in a perforation of the posterior vaginal wall, which was repaired with layered closure. A soft mesh (Bard) was tailored and positioned along the rectum to the pelvic floor, fixed to the rectum and promontory, with posterior vaginal apex attachment.

RESULTS

The postoperative course was uncomplicated. The patient recovered uneventfully with complete resolution of symptoms. Throughout the procedure, mentorship focused on anatomical orientation and intraoperative decision-making when technical challenges are encountered.

CONCLUSION

Redo VMR can be technically challenging, particularly in the presence of prior mesh, dense adhesions and erosion into adjacent pelvic structures. Robot-assisted revision VMR provides enhanced visualization, enabling safer dissection and can potentially improve patient outcomes.

ABSTRACT. OBJECTIVE Tailgut cysts are uncommon congenital lesions that typically arise in the retrorectal space. They predominantly occur in middle-aged women and may present with a wide range of symptoms, including abscess formation, constipation, infertility, and lower abdominal pain. Malignant transformation has been reported in up to 30% of cases, particularly in symptomatic patients. We report a case of a malignant tailgut cyst invading the rectum, treated with a robotic total mesorectal excision. METHODS A 63-year-old woman presented with acute lower abdominal pain and was referred by a gastroenterologist after detection of a presacral cyst perforating through the posterior rectal wall. Initial histopathological examination was negative, and subsequent analysis could not distinguish between a malignant tailgut cyst and a primary rectal adenocarcinoma. Staging investigations showed no distant disease. Magnetic resonance imaging demonstrated close contact with the internal sphincter and the levator ani muscle. RESULTS The interval between symptom onset and surgical treatment was almost four months. Despite the low position of the lesion, a robotic total mesorectal excision with manual coloanal anastomosis and protective ileostomy was performed. Intraoperatively, the tumor was located below the peritoneal reflection and extended posteriorly toward the internal sphincter, necessitating partial posterior internal sphincter resection. The perforation site was clearly visible and remained mucus-producing. Postoperative histology revealed a low-grade mucinous adenocarcinoma arising from a fistulous tract, with negative resection margins. Ileostomy reversal was performed subsequently, and the postoperative course was uncomplicated. CONCLUSIONS This case highlights the substantial risk of malignant transformation in tailgut cysts, particularly in symptomatic patients. Perforation and sphincter involvement may necessitate extended oncological resection. Even in low-lying tumors, a clean total mesorectal excision with partial internal sphincter excision can be achieved using a robotic approach.

ABSTRACT. OBJECTIVE Inguinoscrotal hernias represent up to 6% of all groin hernias in high resource countries. Surgical intervention can be challenging due to increased operative complexity and is associated with higher risk of complications compared to standard groin hernia repair. Evidence for inguinoscrotal hernia management is scarce and often of low quality. Recent HerniaSurge guidelines (2023) stated that, depending on expertise, minimally incasive techniques can be safely employed. For irreducable scrotal hernias however, open repair is described as the default. We present a robot-assisted minimally invasive hybrid approach for irreducible scrotal hernia.

METHODS A 41-year-old obese male (BMI 33) presented with a clinically diagnosed left-sided inguinoscrotal hernia and concomitant umbilical hernia. No preoperative imaging was performed. Given the presence of the umbilical hernia and known benefits of laparo-endoscopic techniques (less chronic pain and faster recovery), a robot-assisted transabdominal approach was chosen. The single-port Da Vinci system was used with access through the umbilical hernia defect. Intraoperatively, a large L3 inguinal hernia with sliding herniation of the colon was identified. Despite meticulous dissection and gentle traction, reduction of the hernia sac and contents was not achievable. A groin counter-incision was performed to facilitate controlled reduction. Definitive inguinal hernia repair was completed using a minimally invasive placed preperitoneal Progrip self-fixating mesh 16 × 12 centimeters. The umbilical hernia was repaired with a 7-centimeter CAB.S.AIR mesh.

RESULTS Total operative time was 126 minutes with minimal blood loss. Complete reduction was achieved without complications. Discharge took place on postoperative day one. Aside for a seroma in the left groin, recovery was uneventful.

CONCLUSIONS This case demonstrates that minimally invasive surgery can safely be performed even in irreducible inguinoscrotal hernias. When intraoperative reduction fails, a hybrid approach of minimally invasive repair with targeted open reduction is feasible while preserving the advantages of posterior mesh placement.