ABSTRACT. Objective: Anastomotic leakage (AL) is a much-dreaded complication after esophagectomy, with early detection specific biomarkers remaining elusive. This exploratory study investigated whether proteomic and metabolomic profiling of pleural fluid could provide insight into potential pleural biomarkers for AL in the early postoperative period.

Methods: Pleural fluid was prospectively sampled on day 4 after transthoracic esophagectomy with intrathoracic anastomosis for cancer, coinciding with the early, mostly subclinical phase of AL. Two AL and two non-AL patients were selected post-hoc according to the Esophageal Complications Consensus Group (ECCG) definition. Proteins and metabolites were separated by methanol precipitation, followed by proteomic and metabolomic analyses using mass spectrometry. An exploratory volcano plot analysis was performed after listwise deletion of missing data, with FoldChange (log2FC) quantifying relative abundance differences between conditions after normalization through log transformation.

Results: Of 1,233 proteins and 326 metabolites detected, 792 (64%) proteins and 199 (61%) metabolites remained after filtering. In the AL patients, of the proteins, 49.6% were upregulated (log2FC:0.0059–4.3505) and 50.4% downregulated (log2FC:−0.0001,−5.8154). The 5 most pronounced upregulated proteins were myoglobin (hemeprotein, log2FC:4.3505), creatine kinase M-type (energy metabolism enzyme, log2FC:3.4964), carbonic anhydrase 3 (antioxidant, log2FC:3.1378), neutrophil collagenase (neutrophil associated enzyme, log2FC:2.8693), and bactericidal permeability-increasing protein (neutrophil associated enzyme, log2FC:2.6690). The five most downregulated proteins were keratins, key structural cytoskeletal components (log2FC:-5.8154,-5.0842). Of the metabolites, 58,3% were upregulated (FC:0.0024,4.2267), and 41.7% were downregulated (log2FC:-4.2294,-0.0009). The 5 metabolites with the most pronounced FC were 11Z-Eicosenoic acid (fatty acid metabolism, log2FC:-4.2994), Etizolam (sedative related metabolite, log2FC:4.2267), Hericene B (fungal associated metabolite, log2FC:3.7378), 11-hydroxyeicosatetraenoate glyceryl ester (inflammatory lipid mediator, log2FC:3.4990), and (-)-cis-Rotenolone (mitochondrial associated metabolite, log2FC:3.2469).

Conclusions: These pilot data demonstrate that, on day 4 after esophagectomy, proteomic and metabolomic differences in pleural fluid may exist between patients with and without AL, suggestive of undiagnosed disease activity. Mass spectrometry could facilitate early postoperative pleural biomarker discovery.

ABSTRACT. Objective Suboptimal initial clinical response (SICR) and recurrent weight gain (RWG) following Roux-en-Y gastric bypass (RYGB) remain challenging clinical problems. Conversion to more hypoabsorptive procedures may improve weight outcomes but is associated with an increased risk of protein malnutrition and nutritional deficiencies. This study reports a single-center experience evaluating the safety and weight-related outcomes of a combined revision of RYGB (CR-RYGB), consisting of proximal revision with optional pouch banding and a more moderate type 1 distalization. Methods Between October 2019 and January 2025, 163 consecutive patients undergoing CR-RYGB at AZ Sint-Jan Hospital were included. Preoperative characteristics, perioperative data, postoperative weight evolution, and short- and long-term complications were analyzed. Results Mean pre-revision body mass index was 41.35 kg/m², with a mean follow-up of 14.3 months. Indications for revision were SICR in 12.3%, formal RWG in 82.2%, and less significant RWG in 5.5%. No conversions or intraoperative complications occurred. Proximal revision consisted of a gastrojejunal sleeve, pouch resizing alone, or redo gastrojejunostomy in 87.1%, 5.5%, and 7.4% of patients, respectively, with pouch banding performed in 45.4%. Mean total alimentary limb length after revision was 507 cm; all distalizations were type 1 Surgerman distalizations. Early and long-term complication rates were 3.7% and 6.7%, respectively. One case of protein malnutrition and one case of intractable steatorrhea required revisional surgery. Mean percentage of total weight loss was 20.26% at 12 months, 22.17% at 2 years, 24.45% at 3 years, and 22.16% at 4 years. Conclusions In this single-center experience, CR-RYGB was associated with acceptable perioperative safety and sustained weight loss following SICR and RWG after RYGB. While these results are encouraging, larger multicenter studies with longer follow-up are needed to better define the comparative effectiveness and metabolic impact of this combined revision strategy.

ABSTRACT. OBJECTIVE This study aimed to evaluate the diagnostic performance of the Konradsson score, assess its association with therapeutic interventions in current clinical practice and investigate whether early delayed gastric conduit emptying (DGCE) predicts the development of late DGCE.

METHODS A retrospective, single-center, observational study was conducted including patients who underwent esophagectomy with gastric conduit reconstruction between March 2023 and December 2024. DGCE symptoms were assessed using the Konradsson questionnaire at postoperative day 14, day 22 and three months. Associations between Konradsson scores, DGCE diagnoses and therapeutic interventions (prokinetics and pyloric dilatations) were analyzed using correlation analyses, chi-square tests, logistic regression and ROC analyses.

RESULTS A total of 102 patients were included. Early DGCE occurred in 31.37% of patients, while late DGCE was diagnosed in 11.76%. Early DGCE did not predict late DGCE at postoperative day 14 or three months and an inverse association was observed at day 21 (OR 0.284; 95% CI 0.095–0.851). Konradsson scores were not significantly associated with the use of prokinetic medication or pyloric dilatation at any time point. ROC analyses demonstrated a reasonable discriminative performance for late DGCE (AUC 0.743–0.833), but with an optimal cut-off value closer to 5 rather than the proposed threshold of 4. Surgical approach and anastomotic location were significantly associated with pyloric dilatation, whereas symptom scores were not.

CONCLUSIONS The Konradsson score demonstrated moderate diagnostic discrimination but limited clinical utility for guiding therapeutic decision-making. Early DGCE did not reliably predict late DGCE. Refinement of the scoring system together with the integration of a pathophysiological classification and a standardized manner of imaging may be required to improve the diagnosis and management of DGCE.

ABSTRACT. Objective: Esophagectomy is a high-risk procedure associated with substantial postoperative morbidity and mortality. Identifying high-risk patients is crucial to reduce postoperative complications and is achieved through a structured preoperative assessment. However, no international consensus currently exists on which investigations should be included in this assessment. This study aimed to describe current international practices in preoperative assessment for esophagectomy and explore attitudes toward international standardization. Methods: An international cross-sectional online survey consisting of 32 questions was conducted between August and November 2025 among specialists involved in the management of patients undergoing esophagectomy for cancer. The questionnaire explored preoperative investigations, decision-making processes, and perspectives on international standardization. An invitation email containing the survey link was distributed to members of the International Society for Diseases of the Esophagus (ISDE). Data were analyzed using descriptive statistics. Results: A total of 133 completed questionnaires from 40 countries were analyzed. Most respondents were upper gastrointestinal (62.4%) or thoracic surgeons (25.6%), and 89.5% worked in academic centers. Considerable variability was observed in preoperative assessment strategies. No routine pulmonary function testing was reported in 24.1%, whereas spirometry and diffusion capacity testing were routinely performed in 72.9% and 33.1%, respectively. Echocardiography was routinely used in 52.6%. Routine exercise testing was not performed in 57.9%, whereas stair climbing testing, the 6-minute walk test, and cardiopulmonary exercise testing were used in 20.3%, 18.8%, and 11.3%, respectively. Frailty assessment was reported by 94.7% of respondents, yet standardized screening instruments were used by 20.3%. Prehabilitation programs were systematically initiated in 51.9% of respondents. Notably, 74.4% indicated that preoperative screening should be more standardized internationally. Conclusions: This international survey demonstrates substantial variability in preoperative assessment for esophagectomy. The strong support for standardization highlights the demand for international guidelines.

ABSTRACT. OBJECTIVE An unrecognized short esophagus is a known technical cause of failure in anti-reflux surgery, for which usual treatment is Collis gastroplasty. However, some authors remain reluctant to perform esophageal lengthening because of concerns regarding increased risks of postoperative dysphagia, fistula formation and esophagitis above the fundoplication. This study aims to report our laparoscopic experience with Collis gastroplasty.

METHODS This retrospective study included 67 patients who underwent anti-reflux surgery with esophageal lengthening performed by a single surgeon between 2013 and 2025. After a follow-up exceeding one year, 46 patients completed a reflux-specific quality of life questionnaire (GERD-HRQL), and 25 underwent an upper gastrointestinal contrast study. Perioperative data, postoperative complications, patient satisfaction, and persistent symptoms were analyzed and correlated with radiological findings.

RESULTS Median age was 60 years. Incidence of previous anti-reflux surgery was 28% and Barrett esophagus was present in 26%. Preoperative hiatal hernia was diagnosed in 92% of patients, with a median length of 6.5 cm (SD=3). The rate of severe complications (Clavien–Dindo>3A) was 10.5% at 90 days, with no postoperative fistula reported. With a median follow-up of 29 months (IQR=43), reoperation for symptom recurrence was required in 7.5% of patients, but only 3% presented with recurrent hiatal hernia. The mean GERD-HRQL questionnaire score was 3.74 (SD=6.66), with a median follow-up of 33 months. 80% of patients reported satisfaction with the procedure. Although 45.7% were still taking daily proton pump inhibitors, only 17.3% did so for persistent symptoms. Reflux severity on contrast studies was significantly reduced postoperatively (W=107, p=0.007). Mispositioned fundoplication was observed in 28% of patients and was significantly associated with lower satisfaction (p=0.011) and higher GERD-HRQL scores, particularly heartburn-related symptoms (p=0.007).

CONCLUSION Collis gastroplasty provides effective reflux symptom control, with an acceptable complication rate for patients undergoing hiatal surgery with a short esophagus.

ABSTRACT. Background: Complication prediction and risk stratification of patients undergoing esophagectomy for cancer is challenging due to surgical complexity, older patients, comorbidities, and inter-institution management differences. Cardiopulmonary exercise testing (CPET) offers objective preoperative assessment of patient fitness, but its predictive value remains unclear. Even though recent meta-analyses have shown difference in CPET values between outcome groups, its predictive value has not yet been evaluated.

Methods: A systematic review, according to the PRISMA guidelines, was conducted by searching PubMed, Embase, Web of Science, Scopus, and CENTRAL for publications up to December 2025. Odds ratios, hazard ratios and 95% confidence intervals were pooled in random-effects meta-analyses for VO2max, VO2 at anaerobic threshold (AT), and VE/VCO2 regarding major complications (Clavien-Dindo ≥ III), cardiorespiratory complications, and overall survival. Heterogeneity was assessed using τ² and I². Risk of bias was evaluated with the QUIPS tool.

Results: Of 1379 articles screened, eight studies were withheld for meta-analysis. Pooled sample sizes were 463 for major complications, 271 for cardiorespiratory complications, and 772 for survival. For cardiorespiratory complications, only VE/VCO2 had ≥1 study available for analysis, its other two CPET variables were excluded from further analyses. Major complications were associated (pooled 95% CI excluding 1) only to VO2max [pOR(pooled OR) 0.90, 95%CI 0.82-0.98; I2: 0%], while VO2 at AT and VE/VCO2 showed no clear association (pOR 0.89-1.05; I2 0-78.2%). No pooled associations were found for cardiorespiratory complications (pOR 0.90; I2 89.7%) or survival (pHR 0.89-1.04; I2 0-58.9%).

Conclusion: VO2max shows a modest association with major complications after esophagectomy for cancer, supporting previous findings based on standardized mean differences (SMD). Future efforts should focus on pooling individual patient data to establish clinically relevant cut-off points.

ABSTRACT. Introduction Metabolic and bariatric surgery (MBS) often improves hepatic steatosis. However, emerging evidence suggests a paradoxical increase in the risk of alcohol use disorder (AUD) and severe alcohol-associated liver disease postoperatively. In this study, we aim to elucidate the interplay between prior MBS, alcohol use and liver health in a high-risk psychiatric cohort. Methods This cross-sectional Belgian study enrolled adult patients admitted for excessive alcohol use to the Urgent Psychiatric Care Unit of Ghent University Hospital (n=36) and to the psychiatric department (PD) of AZ Vitaz between May 2023 and November 2025 (n=147). Informed consent was obtained from all participants. Laboratory results and clinical information were retrieved from electronic medical records and liver assessments with abdominal ultrasound and FibroScan were performed during admission, as well as self-report questionnaires assessing substance use. Results A history of MBS was present in 25,7% (47/183), with 63.8% Roux-en-Y gastric bypass procedures. Patients with prior MBS were more often female (p<0,001) and had a higher body mass index (BMI) (p<0,001). In addition, patients post-MBS were more often admitted to the hepatology department following psychiatric hospitalization (p=0,004). In multivariate analysis, a history of MBS remained independently associated with the presence of advanced chronic liver disease (FibroScan ≥15kPa) after adjustment for BMI, gender and self-reported daily alcohol consumption(p=0,025). Finally, they presented with more advanced liver fibrosis (p=0,008), despite steatosis being equally severe. Within the PD subgroup, the duration of AUD was significantly shorter among patients who underwent MBS (p=0,018). Tobacco use was significantly lower following MBS (p<0,001). On average, AUD developed five years after MBS, although 20% of patients already reported excessive alcohol use prior to the procedure. Conclusions Crucially, one in four admitted patients with AUD had previously undergone MBS, presenting with shorter duration of AUD and more advanced liver fibrosis, emphasizing the multidisciplinary need for follow-up of patients post-MBS.

ABSTRACT. Objective: Anastomotic leakage (AL) is a dreaded complication after esophagectomy for cancer, associated with increased perioperative mortality and long-term morbidity; negative consequences that could be mitigated by early detection and treatment. This study aims to retrospectively assess whether systematic radiological screening (SRS) for AL was able to diagnose patients who did not already exhibit clinical or biochemical signs of possible leakage (PoL), which would otherwise have prompted diagnostic testing.

Methods: Patients undergoing esophagectomy with intrathoracic anastomosis at a tertiary center between 2014 and 2021 were included. Systematic screening consisted of contrast swallow or computed tomography (CT) with per‑oral contrast on postoperative days (POD) 4–5. Patients with positive screening were assessed for following signs suggestive of AL from POD0 to POD5: C-reactive protein (CRP) ≥ 300mg/L, new-onset leukocytosis with white blood cell count ≥ 10*109/L, temperature ≥ 38˚C, tachycardia with ≥ 120 bpm, and presence of atrial dysrhythmia.

Results: Of 53 patients with intrathoracic AL, 49 (92.5%) underwent systematic screening and 9 (17.0%) were diagnosed at screening (contrast swallow 55.6%, CT 44.4%). In all these patients with positive screening, signs suggestive of AL were already present: elevated CRP in 2 (22%), new‑onset leukocytosis in 3 (33.3%), fever in 6 (66.7%), tachycardia in 6 (66.7%), and atrial dysrhythmia in 1 (11.1%). Of note, the 40 (81.6%) patients with negative screening developed AL on median day 9.5 (interquartile range 7-15.25), despite initial screening being negative.

Conclusion: Although early diagnosis of AL is key to its successful management, systematic screening could only diagnose patients who were already exhibiting symptoms or signs suggestive of leakage. With day of AL-diagnosis varying strongly in our cohort, and screening providing a false sense of security in 81.6% of patients, these results advocate for a more patient-tailored, targeted approach to screening for AL.

ABSTRACT. Background Anastomotic leakage (AL) is a well-known complication after esophagectomy. Its etiopathogenesis, however, is not fully understood with current hypotheses failing to capture its full complexity. In colorectal surgery, a link has been established between anastomotic leakage and the phenotypic switch of commensal bacteria to pathogenic collagenase-producing bacteria. In the current study we aimed to explore if collagenase activity might also play a role in AL after esophagectomy for cancer with gastric conduit reconstruction.

Methods Samples were endoscopically collected with cytology brushes at diagnosis of AL (n=4) or delayed conduit emptying (control group,n=3). In AL-patients, anastomoses were first sampled on the side opposite to the AL and second on the AL itself. In control patients two opposite sides were sampled. Collagenase activity was evaluated on a multimode microplate reader using fluorescein-labeled dye quenched collagen by comparing activity at 90-minutes to collagenase from Clostridium histolyticum, and by using Relative Fluorescence Units (RFU) at 12-hours. Samples were grouped according to sampling sequence. Collagenase activity was compared between AL and control patients using the Mann-Whitney U test.

Results Patients with AL were sampled on postoperative day 11-24, on average 2.5±2.1 days after diagnosis, and patients in the control group on days 5-7. AL-severity was grade 2-3 and Clavien-Dindo IIIb-IVb. A non-significant trend for higher average collagenase activity (both sampling sites) was found in the AL group versus in the control group (4.60±3.8 and 0.73±0.5 respectively). Differences in average RFU were however significant in this exploratory cohort (37551±13403 in the AL-group,13835±8573 in the control group; p= 0.034). Of note, in patients with AL, the collagenase activity was similar between samples taken at the AL and on the opposite side.

Conclusion Patients with AL after esophagectomy for cancer had higher collagenase activity on the anastomosis than patients without AL, mirroring earlier research in colorectal surgery suggesting a bacterial etiopathogenesis.

ABSTRACT. Objective Reversal of Roux-en-Y gastric bypass (RYGB) is an uncommon but increasingly relevant procedure as bariatric surgery volumes rise. It is typically reserved for severe, refractory complications such as dumping syndrome, malnutrition, excessive weight loss, or chronic abdominal pain. Although conceptually straightforward, RYGB reversal carries specific anatomical and technical pitfalls. This video presents a case of postoperative dysphagia following RYGB reversal caused by an unfavorable gastro-gastrostomy (G-G) configuration, highlighting an underrecognized mechanism of functional gastric obstruction. Methods The video demonstrates the diagnostic evaluation and surgical correction of severe dysphagia after RYGB reversal. Imaging and endoscopy revealed a widely patent G-G anastomosis without intrinsic stenosis. Intraoperative findings showed a high side-to-side G-G anastomosis on the vertical gastric corpus, creating a long and narrow distal gastric segment with impaired emptying. Revisional surgery consisted of resection of the elongated corpus segment and construction of a hand-sewn end-to-side G-G anastomosis to the horizontal antrum, restoring a straight and more physiological gastric conduit. Key technical considerations and preventive strategies are highlighted. Results Postoperative recovery was uneventful, and the patient was discharged on postoperative day one. Contrast imaging demonstrated prompt gastric emptying. Dysphagia resolved completely within six weeks of revision. Conclusions This case illustrates an important technical pitfall in RYGB reversal. Anastomotic level and orientation play a critical role in postoperative gastric function and may cause functional obstruction despite a patent anastomosis. An end-to-side G-G anastomosis to the horizontal antrum may provide a more physiological reconstruction and help prevent postoperative dysphagia. Awareness of this mechanism is essential for surgeons performing RYGB reversals.

ABSTRACT. Objective – Incisional hernia is a well-known complication of abdominal surgery, however, hernias following cesarean section are likely underreported. A classification system describing five types of cesarean hernias was recently proposed by Zanellato. Subsequently, a sixth type was added, defined as a hernia located at the fulcrum abdominalis, at the anatomical location where the arcuate line joins the lateral border of the rectus abdominis muscle at the EIT ambivium (External oblique -Internal oblique- Transversus abdominis junction).

Methods – We present two cases of two women aged 47 and 43 years, both with a history of two cesarean sections. Each reported intermittent swelling in the left lower quadrant, associated with discomfort during physical activity. In one patient, ultrasound confirmed a 1.5 cm abdominal wall defect lateral to the left rectus abdominis muscle, containing preperitoneal fat and small bowel loops. In the second patient, abdominal CT imaging did not reveal a clear hernia.

Results – Both patients underwent elective robot-assisted transabdominal preperitoneal (r-TAPP ventral) repair with closure of the hernia defect (1.5x1.5 cm and 6x7 cm, respectively) located at the fulcrum abdominalis and placement of a self-fixating preperitoneal mesh. The postoperative courses were uneventful. Both patients were discharged the same day. At follow-up, both patients reported complete resolution of symptoms and physical examination showed a stable abdominal wall repair.

Conclusion – This case highlights the clinical relevance of type 6 cesarean hernias involving the fulcrum abdominalis. Increased awareness of this anatomical weak point and understanding this hernia subtype may facilitate better recognition and enable appropriate surgical management.

ABSTRACT. Objective Splenic tumors are rare, and splenic metastases from solid malignancies usually occur in disseminated disease. Adenoid cystic carcinoma (ACC) is an uncommon salivary gland malignancy characterized by indolent growth and a strong propensity for late distant metastases, most commonly to the lungs, with occasional atypical sites reported. Laparoscopic partial splenectomy represents an alternative to total splenectomy for selected splenic lesions, enabling oncologic resection while preserving splenic function, with acceptable morbidity described in the literature.

Methods A 49-year-old woman treated for ACC of the left submandibular gland by surgical resection and adjuvant radiotherapy subsequently developed pulmonary metastases managed with stereotactic radiotherapy. During follow-up, CT, MRI, and FDG PET-CT revealed a solitary splenic lesion measuring approximately 55 mm, encapsulated, with central necrosis and intense peripheral hypermetabolism, without evidence of other progressive metastatic disease. After multidisciplinary tumor board discussion, a laparoscopic upper-pole partial splenectomy was performed with selective vascular control and preservation of the inferior splenic pole. The postoperative course was uneventful, without complications or transfusion, and the patient was discharged on postoperative day three.

Results Published series and systematic reviews support the feasibility and reproducibility of laparoscopic partial splenectomy for selected benign and malignant splenic lesions, provided patient selection and meticulous vascular control. Preservation of residual splenic tissue may reduce the risk of overwhelming post-splenectomy infection. In splenic metastases, partial or subtotal splenectomy may be considered in highly selected patients with oligometastatic disease and controlled systemic tumor burden. The distinctive metastatic behavior of ACC supports an individualized approach to isolated metastatic sites when locoregional and systemic disease are controlled.

Conclusion This case illustrates the feasibility of laparoscopic partial splenectomy for isolated splenic metastasis from adenoid cystic carcinoma. Supported by evidence on spleen-preserving surgery and the biological behavior of ACC, this approach represents an option in selected patients after multidisciplinary evaluation.

ABSTRACT. OBJECTIVE Laparoscopic retrocaval paraganglioma resection poses surgical challenges due to close proximity to the inferior vena cava (IVC), along with the associated risk of excessive catecholamine release during surgical manipulation. Careful surgical planning and intraoperative management are essential to minimize vascular and hemodynamic complications.

METHODS A 46-year-old male presented with a hypertensive crisis following a varicectomy. He exhibited systolic blood pressures > 220 mmHg and hypertensive pulmonary edema, requiring intensive care unit treatment. A 24-hour urinary collection showed significantly elevated catecholamine levels. An abdominal CT scan revealed a 6.9 x 5.2 cm mass located entirely behind the IVC and medial to the adrenal gland, which was suggestive of a paraganglioma. The mass caused extrinsic compression of the IVC in an anterior direction. A laparoscopic excision of the retrocaval paraganglioma was successfully performed. The procedure began with mobilization of the right liver lobe and a partial Kocher maneuver to achieve full exposure of the IVC. The adrenal gland was carefully mobilized but preserved. To fully expose the tumor surface, the tumor was mobilized both medially and laterally to release its attachments. The tumor was medially luxated from the IVC.

RESULTS The operative time was 210 minutes, with an estimated blood loss of 300 mL. The patient was admitted to the ICU for postoperative observation and blood pressure management. The further postoperative course was uneventful, and the patient was discharged on the fourth day after surgery. Pathologic examination confirmed the diagnosis of paraganglioma with an associated ganglioneuroma.

CONCLUSION Retrocaval paragangliomas can present surgical challenges. However, this case demonstrated the feasibility of a laparoscopic approach.

ABSTRACT. OBJECTIVE We present the case of a 28-year-old woman who underwent laparoscopic sleeve gastrectomy (SG) in 2022 for severe obesity (BMI 46 kg/m²). Postoperatively, she developed dysphagia with intolerance to solids and liquids due to a sleeve stenosis, leading to excessive weight loss (BMI 26 kg/m²). A laparoscopic stricturoplasty with plication of a dilated sleeve segment (June 2024) and a laparoscopic Roux-en-Y (RNY) gastroenterostomy with a bipartition-like configuration (December 2024) failed to relieve symptoms. Persistent malnutrition required total parenteral nutrition, after which the patient’s weight improved (BMI 29 kg/m²). Upper gastrointestinal contrast study demonstrated proximal gastric stasis during solid bolus intake, impaired passage toward both the sleeved stomach and the alimentary limb and distal esophageal contrast retention. Aim to illustrate the surgical management of persistent dysphagia after multiple procedures performed for sleeve gastrectomy stenosis. METHODS In 2025, patient underwent laparoscopic exploration with resection of the gastroenterostomy complex and conversion to RNY gastric bypass. Intraoperative insufflation of the stomach revealed marked sleeve dilation proximal to the gastroenterostomy with preferential passage of the tube into the stenotic sleeve rather than to the alimentary limb, as well as a twist of de alimentary limb distal to the gastroenterostomy. A resection of the stenotic mid-sleeve together with the gastroenterostomy complex was performed. A gastric pouch was created, and a new gastroenterostomy was preformed using circular stapler. A contrast study on postoperative day one showed good passage. The patient was discharged the following day. RESULTS No postoperative complications occurred. At three-month follow-up, the patient reported complete resolution of dysphagia, improved physical strength, a 2-kg weight gain, and successful return to work. CONCLUSIONS Persistent dysphagia after SG requires thorough clinical evaluation and accurate identification of the site and mechanism of obstruction. When imaging studies are inconclusive, laparoscopic exploration may be essential to assess the altered anatomy and provide definitive treatment.

ABSTRACT. Background: Choledochal cysts are rare congenital anomalies, more frequently diagnosed in children but occasionally discovered in adults. Standard treatment involves complete excision of the extrahepatic bile duct, followed by biliary reconstruction. Laparoscopy has become a safe and minimally invasive alternative to open surgery.

Case Report: A 22-years-old female presented to the emergency department with epigastric pain radiating to the back. Imaging revealed a type IC choledochal cyst (Todani classification). A complete laparoscopic resection was performed, followed by a Roux-en-Y hepaticojejunostomy. The procedure was carried out in three stages: dissection with intraoperative cholangiography, extracorporeal preparation of a 60 cm jejunal limb, and intracorporeal anastomosis. The dissection required the combined use of monopolar, bipolar, and ultrasonic energy instruments. The jejunal limb was routed via a transmesocolic approach. The anastomosis was performed with interrupted 5-0 PDS sutures. The surgery lasted 400 minutes without significant blood loss. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 6.

Conclusion: Laparoscopic management of choledochal cysts is safe and effective in adults. The transmesocolic Roux-en-Y approach remains the standard for biliary reconstruction.

ABSTRACT. Background Perineal hernia is an underreported complication after extensive pelvic surgery, with recent studies showing incidences up to 26%. Despite the growing clinical relevance, there is no gold standard technique for perineal hernia repair due to scarce data, lack of standardization, and low-level evidence regarding any surgical approach or technique.

Traditional primary closure has largely been abandoned in favour of (synthetic) mesh repair, however, recurrence rates remain high. Emerging evidence suggests that combining mesh reinforcement with tissue flap reconstruction may substantially reduce recurrence, although robust comparative data are still lacking. Robotic abdominal repair has gained attention for its enhanced visualization, manoeuvrability and suturing precision, features that are especially advantageous within the confined pelvic space.

A 77-year-old male presented with a symptomatic perineal hernia following extralevator abdominoperineal excision (ELAPE) with partial sacrectomy in 2018 and right hemicolectomy in 2023. Given the complex surgical history, a combined reconstructive strategy incorporating synthetic mesh reinforcement and rectus abdominis muscle flap coverage was selected.

Objective This video report aims to demonstrate the feasibility and technical aspects of a fully robotic abdominal approach to complex perineal hernia repair.

Methods As the right rectus abdominis muscle was designed for flap reconstruction, all trocars were placed in the left hemiabdomen.

The defect was measured, after which a 20×20 cm Dynamesh was introduced cone-like in the pelvis. The mesh was fixed posteriorly with tackers to the residual sacrum, laterally with interrupted sutures, and anteriorly with a continuous suture. Bipolar forceps, a monopolar curved scissors and a vessel sealer were used to dissect the rectus abdominis muscle towards caudally, maintaining the inferior epigastric pedicle. The abdominal fascia was reapproximated, and both the flap and residual greater omentum were placed over the mesh.

The patient was discharged on postoperative day 21.

ABSTRACT. Background: Surgical resection of perihilar cholangiocarcinoma (PHC) remains the only curative treatment.1, 2 Although minimally invasive liver surgery has expanded, major hepatectomies for PHC remain limited because of the technical demands of hilar lymphadenectomy and biliary reconstruction, which are challenging in laparoscopy. Despite the technical advantages of robot-assisted surgery, its role remains debated when it comes to PHC surgery.3 The intent of this video is to present the technique of a robot-assisted extended hepatectomy with biliary reconstruction.

Methods: A 63-year-old woman with no significant past medical history was diagnosed with PHC following incidental cholestasis discovery. Magnetic resonance imaging and computed tomography revealed a 20-mm Bismuth-Corlette type IIIa PHC, confirmed as well-differentiated on endobiliary biopsy. Preoperative right portal vein embolization enabled future left lobe volume optimization (39% of total liver volume).

Results: A robot-assisted right trisectionectomy with main biliary confluence resection (H145678-B), lymphadenectomy (stations 7, 8, 9, 12, 13), and hepaticojejunal reconstruction was performed using the Da Vinci Xi® system and a standard multiport configuration (four 8 mm robotic trocars and one 12 mm assistant trocar). Operative time was 400 minutes, and blood loss was 150 mL. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 5 after drain removal. Histopathology confirmed a well-differentiated pT1N0(0/13)M0R0 PHC.

Conclusions: This case demonstrates the feasibility and safety of robot-assisted extended hepatectomy with biliary reconstruction for PHC in a highly selected patient. Robotic assistance may facilitate precise dissection and reconstruction in the hilum, supporting broader adoption in expert centers pending further comparative data.

ABSTRACT. Objective We present the case of a 55-year-old women with a refractory marginal ulcer after One Anastomosis Gastric Bypass (OAGB). The patient underwent a laparoscopic OAGB in 2013 due to a BMI of 51 kg/m² (128 kg). Postoperatively, she reached a BMI of 26 kg/m². In 2021, she developed a marginal ulcer that was initially successful treated with high-dose proton pump inhibitor (PPI). In 2023 she presented with a recurrence of the marginal ulcer. Despite adequate PPI treatment, the patient developed a perforation at the ulcer site and underwent laparoscopic suturing in January 2024. Follow-up gastroscopy 11 months later demonstrated persistence of the marginal ulcer. Given the refractory nature of the ulcer, the patient underwent a resection of the OAGB anastomosis and conversion to Roux-en-Y gastric bypass (RYGB). The aim of this video is to demonstrate the surgical technique and outcome of resection of the OAGB anastomosis with conversion to RYGB for the treatment of a refractory marginal ulcer. METHODS The procedure was performed laparoscopically. Inspection revealed a retracted lesion on the posterior aspect of the small bowel distal to the gastroenterostomy. The efferent limb was transected first, followed by the afferent (biliopancreatic) limb. After dissection, the gastric pouch was transected using a linear stapler. The original 150-cm biliopancreatic limb was shortened to 70 cm. A new gastroenterostomy was created 70 cm from Treitz using a 25-mm circular stapler. An incomplete staple line was closed with barbed sutures. A 50-cm alimentary limb was created. RESULTS Postoperative contrast study showed no leakage. The patient was discharged on day two without complications. During follow-up, weight remained stable (BMI 26 kg/m²) with complete symptom resolution. CONCLUSIONS In patients with refractory marginal ulcers after OAGB conversion to RYGB with resection of the anastomosis is a safe and effective treatment option when medical therapy fails.

ABSTRACT. OBJECTIVE Gastric fistula is the most serious post operative complication in sleeve gastrectomy. With the development of endoscopic techniques, several alternatives have been used for the treatment of gastric fistula such as endoprosthesis (pigtails catheter, esosponge, stent and VAC-stent), biologic glue and clips. A radical surgical treatment such as total gastrectomy is recommended after the unsuccessful results of endoscopic treatment. Due to the high risk of functional sequel, an alternative is the construction of a gastrojejunal anastomose ‘en Y’ directly connected to the fistula’s hole, also called fistulo-jejunostomy. Here, we present the management of a patient successfully treated by laparoscopic approach.

METHODS We present the case of a 60-year-old woman who underwent laparoscopic sleeve gastrectomy for morbid obesity (BMI 64.9 kg/m²). Three months postoperatively, a proximal staple-line gastric fistula was diagnosed. Management included multiple antibiotic courses, repeated pigtail drainages, and endoscopic stent placement one year after surgery. Three years later, the patient underwent a septic shock requiring intensive care. The prosthesis was removed two years afterward, followed by fistula recurrence one month later, treated with placement of a new prosthesis. Due to persistent fistula five years after the initial surgery and failure of endoscopic treatment, the decision to perform a laparoscopic Roux-en-Y fistulojejunostomy was retained.

RESULTS Postoperative course was uneventful, and the patient was discharged at postoperative day 8. At long term follow-up, she reported a total resolution of symptoms.

CONCLUSIONS The laparoscopic fistula-jejunostomy ‘en Y’ approach for the treatment of chronic gastric fistula post sleeve gastrectomy is safe and effective when endoscopic treatments are unsuccessful.

ABSTRACT. An exploratory robotic-assisted thoracoscopy was performed using the Da Vinci robotic system. An 11-mm trocar was inserted into the left 7th intercostal space along the mid-axillary line, in addition to the three trocars already in place at the left 3rd, 5th, and 7th intercostal spaces in an anterior position. After adequate exposure, the pericardium was opened anterior to the phrenic nerve, which was found to be located very posteriorly. The left atrial appendage, with a lobulated appearance, was clearly visualized. Intraoperative transesophageal echocardiography confirmed the absence of thrombus within the left atrial appendage. Measurement of the left atrial appendage was performed using the sizing guide, yielding a diameter of 35 mm. A 35-mm AtriClip Pro-V2 was then deployed. Exposure was achieved using a grasping forceps, and the left atrial appendage was carefully positioned within the AtriClip, respecting the native anatomy. The clip was successfully deployed. Final transesophageal echocardiographic assessment confirmed complete occlusion of the left atrial appendage, with no residual flow.

ABSTRACT. Objective: Post-operative hypoparathyroidism (HypoPTH) is the most common complication after total thyroidectomy. It has been proven that malabsorptive bariatric surgery can be one of the risk factors of its development. The aim of the study was to assess the incidence, behaviour, treatment, and follow-up of hypocalcaemia after total thyroidectomy in patients with a history of malabsorptive bariatric surgery, considering the rising of the prevalence of the obesity and the surgery related to it.

Methods: This retrospective cohort study included patients who underwent total thyroidectomy at a Belgian tertiary referral centre, between 2010 and 2021. Patients with prior malabsorptive bariatric surgery (n = 15) were matched 1:3 by age and indication for thyroid surgery to controls without a history of bariatric surgery (n=45). Anamnesis and peri-operative data, pre- and postoperative calcium levels, postoperative parathyroid hormone (PTH) levels, incidence of hypoparathyroidism, need for calcium supplementation and six-weeks follow-up data were analysed.

Results: Early postoperative hypoparathyroidism occurred in 40% of patients in the bariatric group and 42% in the control group (p=0.88). Postoperative calcium supplementation was required in 40% of the bariatric group, compared to 33% of the control group (p=0.64). The prevalence of hypocalcaemia requiring supplementation at six weeks post thyroidectomy was identical in both groups (7% vs. 7%, p=0.98).

Conclusions: A history of malabsorptive bariatric surgery did not significantly increase the risk of hypocalcaemia following total thyroidectomy. Despite slightly lower postoperative calcium levels in the bariatric group, the incidence of hypoparathyroidism and need for calcium supplementation were comparable.

ABSTRACT. OBJECTIVE Acute cholecystitis is a common condition associated with a substantial healthcare burden. The gold standard treatment is early (same-admission) cholecystectomy; however, despite strong scientific evidence, guideline adherence remains limited. The Dutch CHESS aimed to evaluate nationwide variation in treatment and identify targets for improvement.

METHODS The Dutch CHESS is a nationwide, prospective, observational cohort study conducted in 67 Dutch hospitals. All patients with radiologically confirmed cholecystitis were prospectively included between April 1 and September 30, 2024, and followed for six months. Guideline adherence was defined as the proportion of operable patients who underwent early cholecystectomy. Inoperability was defined as ASA class IV, necrotizing pancreatitis, symptom duration >7 days, cholecystoenteric fistula, hostile abdomen, or refusal by the patient or anesthesiologist. Mixed-effects models were used to assess the adjusted association between guideline adherence and morbidity (intraoperative or Clavien–Dindo ≥2 complications, emergency department presentation, or unplanned readmission), severe complications (Clavien–Dindo ≥3a), and length of hospital stay.

RESULTS A total of 3,382 patients were included, of whom 2,894 were considered operable. Of these, 2,260 patients (78%) were treated in accordance with the guideline. Guideline adherence varied widely between hospitals (46–92%). The most frequently reported reasons for not performing early cholecystectomy were prolonged symptom duration (39%), comorbidity (19%), and mild symptoms (15%). Forgoing early cholecystectomy was associated with higher morbidity (35% vs. 19%; OR 1.85; 95% CI 1.48–2.32), more severe complications (20% vs. 7%; OR 2.51; 95% CI 1.89–3.33), and a longer hospital stay (median 7 vs. 3 days; ratio 1.85; 95% CI 1.74–1.98).

CONCLUSIONS In the Netherlands, 22% of operable patients with cholecystitis do not undergo early cholecystectomy, with substantial nationwide variation. Symptom duration is the most important reason for deviation from the guideline. Forgoing early cholecystectomy is strongly associated with worse clinical outcomes.

ABSTRACT. Objectives: Aorto-iliac disease is common in end-stage renal disease and may contraindicate kidney transplantation (KTx) because of severe vascular calcifications. Aorto-iliac bypass surgery can sometimes enable graft implantation in highly comorbid patients. Transplantation onto a vascular prosthesis can be technically challenging and perioperative morbidity may be increased, potentially impacting graft survival. Outcome data remain limited. This study aimed to report our experience.

Methods: We conducted a retrospective study including deceased-donor KTx performed between January 2007 and November 2024. Patients transplanted onto an aorto-iliac bypass (AIB group) were compared with patients transplanted onto native vessels (control group).

Results: Among 886 adult deceased-donor KTx, 33 grafts (3.7%) were implanted onto a vascular prosthesis. In the AIB group, 27% of patients had a prior bypass for cardiovascular indications, while 73% underwent AIB specifically to enable KTx. Recipients and donors were significantly older in the AIB group (63 ± 16 vs. 54 ± 13 years, p = 0.001; 51 ± 12 vs. 45 ± 14 years, p = 0.007, respectively). Warm ischemia time (=suture) was slightly longer in the AIB group (40.7 ± 8.9 vs. 37.0 ± 10.3 minutes). Perioperative transfusion was required in 39% of AIB patients, and 12% experienced major complications. Early graft loss occurred in 9% of AIB patients. Primary non-function was more frequent in the AIB group (3/33, 9.1%) than in controls (25/853, 2.9%; p = 0.047), as was delayed graft function (9/33, 30% vs. 123/853, 14.9%; p = 0.024). Overall graft survival was shorter in the AIB group (9.2 vs. 12.7 years, p = 0.003).

Conclusions: In one of the largest series reported, KTx onto an aorto-iliac bypass was feasible. Although associated with higher perioperative morbidity and somewhat shorter graft survival, the outcomes remain satisfactory. Careful patient selection is essential, and further studies using matched controls are needed to better assess long-term outcomes.

ABSTRACT. Objective: Post-operative hypoparathyroidism (HypoPTH) is the most common complication following total thyroidectomy. In the previous years, autofluorescence (AF) detection and indocyanine green (ICG) injection were used to visualize the parathyroid glands (PGs) during the surgery, and they were assessed to be useful to prevent HypoPTH. The aim of the study was to analyse the impact of AF and ICG to minimize the risk of HypoPTH.

Methods: A single-blinded randomized controlled trial with parallel assignment was conducted in a single Belgian tertiary referral centre. The use of AF with ICG injection was compared to the gold standard of visual identification of PGs. The primary outcome was the occurrence of HypoPTH six weeks after surgery.

Results: 50 patients were enrolled, 25 for each arm of the study. A total of 80 PGs were visualized in the AF and ICG group, compared to 76 of the control group (p=0.516). The prevalence of HypoPTH was not significantly different (32% in the AF and ICG group vs. 36%, p=0.765). Interesting, more patients in the AF and ICG group had lower levels of PTH (<10 pg/mL) 4 hours after the surgery (28% vs. 12%) and developed early hypocalcaemia (12% vs. 8%, p=0.781). All patients recovered six-weeks after the surgery.

Conclusions: This study did not demonstrate a significant benefit of using AF with ICG to prevent transient HypoPTH. Even though more PGs were visualized in the AF and ICG group, the prevalence of HypoPTH and hypocalcaemia seems to be higher in this group, but the differences were not statistically significant.

ABSTRACT. Background: Seroma formation remains a common complication after abdominoplasty, with reported rates of 5–30%. Although drainage and quilting sutures are widely used, fibrin sealants may represent an alternative for dead space management. This study evaluated whether ARTISS® fibrin sealant reduces seroma formation and postoperative complications after abdominoplasty.

Methods: A retrospective single-center study included 40 patients undergoing primary abdominoplasty between August 2022 and June 2025. Patients were divided into an ARTISS group (n = 21), receiving 4 mL of sprayed fibrin sealant before flap redraping, and a control group (n = 19), undergoing standard surgery without sealant. Quilting sutures were not used. All procedures were performed by a single surgeon using a standardized technique. Statistical analyses were performed with a significance threshold of p < 0.05.

Results: Baseline characteristics were comparable between groups. Overall postoperative complications occurred in 14.3% of the ARTISS group versus 31.6% of controls (p = 0.265). Seroma formation occurred only in the control group (10%, n = 4) and was absent in the ARTISS group (p = 0.042). Rates of hematoma, wound dehiscence, and infection were similar. In uncomplicated cases, drain duration tended to be shorter in the ARTISS group (5.94 vs. 7.80 days, p = 0.161). Length of hospital stay did not differ significantly between groups.

Conclusion: ARTISS® fibrin sealant significantly reduced postoperative seroma formation after abdominoplasty. Although no significant differences were observed in overall complication rates or hospital stay, ARTISS® appears to be a valuable adjunct for dead space management when quilting sutures are not used. Larger prospective studies are needed to confirm these findings.

ABSTRACT. OBJECTIVE

To report a unusual case of extensive necrotizing pneumonia involving an entire pulmonary lobe with paramediastinal abscess formation, highlighting diagnostic pitfalls, role of thoracic surgery, and therapeutic challenges related to parenchymal necrosis and atypical abscess localization.

METHODS

We report the case of a 47 YO man with 30 pack-year smoking history, admitted for progressive right-sided abdominal pain associated general deterioration. Biological assessment showed severe inflammatory syndrome, anemia, and hypoalbuminemia. Abdominal CT-scan performed for abdominal pain incidentally revealed large right pulmonary collection. Chest CT-scan demonstrated complete necrosis of right upper lobe with large air–fluid level extending to a paramediastinal cavity, raising suspicion of an aggressive infectious process. Review of prior imaging revealed pre-existing emphysematous bulla in same location, suggesting secondary infection. Bronchoscopy showed abundant purulent secretions without endobronchial obstruction. Given the extent of parenchymal destruction, atypical mediastinal extension, thoracic surgical consultation was requested to assess indication for drainage versus resection.

RESULTS

Microbiological cultures identified Haemophilus influenzae and Streptococcus pneumoniae, consistent with an aggressive necrotizing infection. CT-guided percutaneous drainage of the paramediastinal cavity was performed due to deep location and high surgical risk. Location and morphology of collection suggested infection of a pre-existing emphysematous bulla, making surgical access challenging. Clinical and biological parameters improved under antibiotic therapy and drainage. Follow-up imaging demonstrated partial regression of abscess and stabilization of necrotic area. Surgical resection was discussed but deferred due to favorable evolution.

CONCLUSION

Extensive parenchymal necrosis involving an entire pulmonary lobe with paramediastinal extension is an exceptional presentation, most often related to highly aggressive pathogens or infection of pre-existing emphysematous bullae. This case highlights the key role of thoracic surgeons in evaluating drainage strategies, timing of surgery, and feasibility. In such complex situations, conservative management combining prolonged antibiotics and image-guided drainage may allow avoidance of high-risk emergency surgery, with delayed resection reserved for selected cases.

ABSTRACT. Objectives Right middle lobe (RML) atelectasis may occur in severe emphysema. Chronic RML collapse is traditionally considered irreversible, the evolution following lung volume reduction surgery (LVRS) has not been described. This study evaluated radiological and functional reversal of RML atelectasis after LVRS.

Methods We retrospectively analyzed our prospectively maintained database of all LVRS-procedures performed between 2018 and 2025. Patients with radiological evidence of chronic RML atelectasis were included, without exclusion criteria. RML-volume was quantified using single-observer manual slice-by-slice CT segmentation preoperatively and at three months postoperatively, with re-expansion expressed in cm³. Preoperative lobar perfusion data of the RML were extracted from nuclear imaging. Pulmonary function (FEV₁, RV, DLCO, 6MWD) and quality of life (QoL) outcomes (CAT, SGRQ) were assessed at baseline and three months.

Results Five female patients (median age 71 years) were identified, all treated by video-assisted thoracoscopic LVRS, predominantly unilateral (n=4). Emphysema morphology and surgical targets are summarized in the table. Median air-leak duration was two days, no mortality occurred. Postoperative CT demonstrated RML re-expansion in 4/5 patients (median +41 cm³, range +1 to +439 cm³; p=0.031). In three patients with available perfusion data, preoperative RML perfusion was 1.1%, 0% and 4.5%, all demonstrated postoperative volumetric re-expansion. Median FEV₁ improved from 29% to 38% predicted, accompanied by a reduction in RV (-50% predicted). DLCO remained stable. Exercise capacity improved (Δ6MWD +30m) and QoL improved (-14 CAT; -14 SGRQ).

Conclusion RML atelectasis in severe emphysema appears reversible after LVRS. Quantitative CT demonstrates middle lobe re-expansion even in the presence of minimal perfusion. These findings suggest that middle lobe atelectasis may represent a dynamic, compressive phenomenon rather than irreversible scarring.

ABSTRACT. OBJECTIVE The VASQIP database has indicated a decrease in surgical resident autonomy in the United States from 2004-2019. The primary objective of the present study was to assess the evolution of surgical resident operative autonomy in Flanders from 2013-2024. A secondary objective was to assess the effect of experience (seniority), gender and hospital type (universitary versus non-universitary).

METHODS Surgical resident operative autonomy data were obtained from the Medbook database. We used ordinal logistic regression (proportional odds model) to estimate the association between calendar year and the level of operative autonomy (A: assisting the surgeon, S1: operated under direct supervision, supervisor is scrubbed, S2: same, supervisor unscrubbed, Z: without direct supervision, T: teaching, acting as supervisor). Models were adjusted for resident experience, gender, hospital type (university vs non-university), and number of residents. Procedure type was not included as a predictor. To account for within procedure clustering standard errors were adjusted. Data on 900.407 surgical procedures were eligible for analysis.

RESULTS Calendar year had no significant impact on resident operative autonomy in our sample. Per year increase in experience (seniority) the odds of being in a higher autonomy level increased by 38.2 %. Female residents had a 15.3 % lower odds of being in a higher autonomy level. A separate analysis, dichotomizing A versus S1, S2, Z and T yielded a similar difference. Residents in a university setting had a 20.7 % higher odds of being given higher autonomy.

CONCLUSIONS There was no significant difference in operative autonomy across the examined time period. Female residents tend to be given less autonomy. Universitary institutions tend to give more operative autonomy.

ABSTRACT. Background: Platypnea–orthodeoxia syndrome (POS) is a rare condition characterized by positional dyspnea and arterial desaturation in the upright position, typically caused by a right-to-left shunt. Most often associated with patent foramen ovale (PFO) or atrial septal defect, POS may be unmasked by anatomical or hemodynamic changes after lung surgery. Case presentation: We report the case of a 70-year-old woman who developed progressive dyspnea and hypoxemia in upright position following right bilobectomy, with poor response to increased FiO₂ and marked improvement when supine. Arterial blood gas analysis confirmed orthodeoxia, and echocardiography with contrast enhanced bubble study demonstrated a right-to-left shunt through a PFO. The patient underwent a percutaneous closure of the defect, resulting in complete resolution of symptoms and normalization of oxygenation. Discussion: Literature review identified a limited number of reported cases of POS after lung surgery. The pathophysiology involves altered atrial geometry, mediastinal shift, or changes in intrathoracic pressure gradients that facilitate shunt flow. Awareness is essential to avoid misdiagnosis and treatment delay. Although a rare condition we suggest to include a routine echocardiography in preoperative workout to document a patent foramen ovale (PFO) or atrial septal defect in patients undergoing major lung resections. Preoperative closure of the PFO can be considered in major lung resections to prevent POS. Especially as early patient mobilization is advocated as one of the key elements in postoperative outcome since the introduction of Enhanced Recovery After Surgery (ERAS) protocols. Conclusion: POS is a rare but important cause of postoperative hypoxemia after major lung resection. Recognition of the postural nature of symptoms is crucial. Preoperative echocardiographic assessment should be considered and perhaps adopted into the guidelines. Preoperative PFO closure can considered in selected patients to prevent time loss in the recovery of the patient and consequently improving the outcome after surgery.

ABSTRACT. Objective Lung volume reduction surgery (LVRS) is an established treatment for selected patients with severe emphysema. However, prolonged air-leak (PAL) remains the most frequent complication, with a reported incidence of 30-50%, contributing significantly to postoperative morbidity. Here we aim to analyze the incidence of air-leakage (AL) and investigate risk factors in a minimally invasive program.

Methods In this prospective, single-centre analysis, 178 patients underwent 213 elective LVRS-procedures between 01/2021 and 12/2024. All surgeries were conducted via VATS. Patients were stratified into three groups according to postoperative AL duration: no AL, short-duration AL (≤7 days), and PAL (>7 days). A multivariable regression model was used to identify risk factors for PAL. Survival was analysed using Kaplan–Meier curves with Cox regression.

Results Postoperative AL occurred in 109 procedures (51%), including 77 (36%) short AL and 32 (15%) PAL. PAL incidence varied by procedure type, occurring in 19% after unilateral, 6% after one-stage bilateral, 23% after first-stage bilateral, and 14% after staged bilateral procedures (p=0.039). Risk factors for PAL versus no/short AL included the presence of AL at the end of surgery (OR 19.296 (6.745-55.202), p<0.0001), AL on postoperative day one (OR 5.436 (1.545-19.125), p=0.0083), increased stapler use (OR 1.207 (1.094-1.332), p=0.0002), chronic systemic steroid use (OR 6.002 (1.685-21.374), p=0.0057), and type of surgical approach. One-stage bilateral was associated with lower risk than unilateral (OR 0.148 (0.040-0.543), p=0.0039), unilateral first-stage (OR 0.129 (0.026-0.632), p=0.0115) and second-stage bilateral surgery (OR 0.137 (0.029-0.664), p=0.0118). Survival did not differ between patients with PAL and those without or with short-duration AL.

Conclusions AL occurred in over half of LVRS procedures, with PAL in 15% of cases. Early postoperative AL and chronic steroid use were independently associated with PAL, emphasizing the need for preoperative and intraoperative preventive strategies with systematic AL assessment before intubation to reduce postoperative air-leak risk.

ABSTRACT. Introduction Small suspicious lung lesions present a challenge for thoracic surgeons relying on direct visualisation, anatomical repairs or digital palpation. Therefore computed tomography (CT) -guided percutaneous coiling/needle biopsy (PTNB) is often seen as a well-recognized and relatively safe marking method for coil localization guided video-assisted thorascopic surgery. Systematic air embolism (SAE) is a rare, often asymptomatic, complication of CT-guided percutaneous lung biopsies or coiling.

Case report We present a case of a 66 year old male, who , preoperatively underwent CT-guided percutaneous coiling for a suspicious nodule in the left upper lobe to facilitate a wedge resection. The procedure was performed under local anaesthesia. Placement of the coil was technically uneventful, the patient did not cough or breathe improperly while the needle was inserted and positioned. Control scan, after coil placement showed , massive amount of air in the aorta. At the same time the patient became unresponsive, cyanotic and gasping for air. Despite resuscitation efforts, patient died. Massive air embolism was the final diagnosis.

Discussion The incidence of SAE following CT-guided PTNB is reported between 0.06% to 4.8% with a mortality of approximately 0.0002% in the largest series. Prognosis following SAE primarily depends on the quantity of air entering the vascular system. Radiologic confirmation is done by brain and chest CT. Early treatment of a SAE consists of prompt administration of 100% oxygen and placing the patient in the left lateral decubitus position with lowering of the head in an effort to increase the intracavitary pressure of the left atrium and avoid cerebral embolization of air.

Conclusion We wanted to report a very rare, but potential lethal complication of coil placement. Objectif is to create awareness. Review of the literature shows some treatment strategies but no clear measures for prevention beside caution in lesion close to vascular structures.

ABSTRACT. OBJECTIVE To evaluate the feasibility and early surgical outcomes of neoadjuvant chemo-immunotherapy in patients with locally advanced and selected oligometastatic non-small cell lung cancer.

METHODS We retrospectively analyzed consecutive patients with non-small cell lung cancer treated with neoadjuvant chemo-immunotherapy with curative intent between 2020 and 2025. The cohort included patients with stage II-III disease and selected patients with oligometastatic stage IV disease. Collected data included tumor stage, surgical resection, type of surgery, surgical approach, pathological response, and early postoperative outcomes.

RESULTS A total of 76 patients were included, comprising 21 with stage II-III disease and 55 with oligometastatic stage IV disease. Overall, 32 patients(42.1%) underwent surgical resection, including 21 of 21 (100%) with stage II-III disease and 11 of 55 (20.0%) with stage IV disease. In stage II-III patients, surgery consisted mainly of lobectomy (85.7%), with segmentectomy(9.5%) and pneumonectomy (4.8%) also performed. Surgical access was predominantly open thoracotomy (81.0%), while video-assisted thoracoscopic surgery and robotic approaches were each used in 9.5% of cases. A major pathological response (residual viable tumor less than or equal to 10%) was observed in 42.8% of patients, including a complete pathological response(0% viable tumor) in 19.0%. Among stage IV oligometastatic patients, 11 of 55(20.0%) underwent surgery. Procedures included lobectomy in 66.7%, pneumonectomy in 16.7%, and segmentectomy in 8.3%. Surgical access was mainly via open thoracotomy(75.0%). A major pathological response was observed in 27.3%, including complete pathological response in 18.2%. Notably, 7 of the 11 resections(64%) were performed from 2024 onward, reflecting evolving practice patterns.

CONCLUSIONS Neoadjuvant chemo-immunotherapy is feasible and safe in routine clinical practice for patients with locally advanced and selected oligometastatic non-small cell lung cancer. This strategy enabled surgical resection with favorable pathological responses. These real-world data support the potential expansion of surgical indications in carefully selected oligometastatic cases, warranting further investigation in prospective trials.

ABSTRACT. Objective: Robot-assisted laparoscopic aortobifemoral bypass has been introduced as a minimally invasive alternative to open surgery for advanced aortoiliac occlusive disease, with the potential to reduce surgical trauma, blood loss, and wound-related complications. This study aimed to evaluate the efficacy and perioperative morbidity of this robotic approach and to assess its advantages and limitations.

Methods: A single-centre retrospective study was conducted using a prospectively maintained database of robot-assisted laparoscopic aortobifemoral bypass procedures performed between August 2019 and May 2025. One hundred and fourteen patients were included, with follow-up ranging from 1 to 6 years. Primary endpoints were post-operative bleeding, graft infection, ischemic colitis, mortality, primary graft patency, and aortic clamping time. Complications were graded using the Clavien–Dindo classification. Secondary endpoints included length of hospital stay and intensive care unit stay. To assess the learning curve, outcomes of the first 30 procedures were compared with those of the subsequent 84 using multiple imputation and propensity score–adjusted analyses.

Results: Mean patient age was 61.5 years, and 70% presented with TASC D lesions. Mean operative time was 189 minutes, with a mean aortic clamping time of 39 minutes. The conversion rate was 2.6%. Intraoperative blood loss greater than 500 mL occurred in 14.9% of patients. Major post-operative complications (Clavien–Dindo ≥ IIIa) occurred in 7% of cases, including early graft infection (3.5%), re-intervention for bleeding (1.7%), and ischemic colitis (0.9%). Primary graft patency at 48 months was 92.9%. Mean hospital stay was 7 days, including 1.24 days in intensive care. One patient (0.9%) died within 3 months post-operatively.

Conclusion: Robot-assisted laparoscopic aortobifemoral bypass appears to be a safe and effective minimally invasive alternative to open repair, providing favourable midterm patency, low conversion rates, and a short learning curve. Further comparative studies are warranted.

ABSTRACT. OBJECTIVE

In current guidelines, conservative treatment with rigorous blood pressure control is the primary treatment in uncomplicated Stanford type B (DeBakey type III) aortic dissections. Thoracic endovascular aortic repair (TEVAR) is reserved for complicated cases. However, the optimal timing of TEVAR remains controversial. This study aimed to evaluate the impact of timing on clinical, functional and radiological outcomes after TEVAR.

METHODS

In this retrospective single-center study, all patients who underwent TEVAR for type B aortic dissection between January 2010 and December 2024 were included. Patients were stratified according to timing of intervention into acute (group A: treated within ≤14 days), subacute (group B: 15–90 days), and chronic (group C: >90 days) groups. Primary endpoints were all-cause mortality and intervention-free survival (defined as any aortic-related intervention). Secondary endpoints included aortic remodeling, blood pressure evolution, and functional outcome (WHO Performance Status). Data were collected from an anonymized database. Outcomes were analyzed with a follow-up period of three years.

RESULTS

Sixty-four people were included: 33 in group A, 25 in group B, and 6 in group C. Technical success was achieved in 97% of procedures. Three-year overall and intervention-free survival rates were 82% and 69%, respectively. Individuals in group B demonstrated the most favorable outcomes, with lower mortality (A: 22%, B: 11%, C: 25%), fewer major complications (A: 41%, B: 13%, C: 17%), and the highest rate of aortic remodeling (A: 76%, B: 88%, C: 60%). Systolic blood pressure decreased significantly after TEVAR with sustained long-term stabilization. No cases of spinal cord ischemia were observed. Functional outcome was excellent, with 94% of patients remaining fully independent at follow-up.

CONCLUSIONS

These findings support a potential benefit of TEVAR in the subacute phase after uncomplicated type B aortic dissection, although larger multicenter studies are required to definitively determine the indication and optimal timing.

ABSTRACT. OBJECTIVE Fenestrated endovascular aortic repair is a well-established treatment option for complex aortic aneurysms. Bridging stent grafts play a crucial role in connecting the fenestrated aortic endograft to the target vessels. This single-center study aimed to evaluate the early and mid-term clinical outcomes of the iCover stent graft implanted as bridging stent during fenestrated endovascular aortic repair.

METHODS All patients treated with at least one iCover stent graft as a bridging stent during fenestrated endovascular aortic repair between December 2022 and June 2024 were included. Data were prospectively collected and retrospectively analysed. Recorded variables included patient demographics, bridging stent diameter and length, technical success, reinterventions, occlusions and postoperative adverse events. Computed tomography angiography was performed before discharge or within one month after the procedure. One-year follow-up consisted of computed tomography angiography or duplex ultrasound with additional abdominal radiography in case of severe renal insufficiency(eGFR <30ml/min/1,73m2).

RESULTS A total of 41 patients (83 percent male) were included with 141 fenestrations treated using an iCover as bridging stent. Technical success rate was 97.6 percent with one failure due to a type I C endoleak. Thirty-day mortality was 2.4 percent with one in-hospital death. Primary patency was 100 percent throughout the study period. During a median follow-up of 21 months (range 18–24 months), freedom from target vessel instability was 98.5 percent.

CONCLUSIONS Early and mid-term results of the iCover stent graft used as a bridging stent in fenestrated endovascular aortic repair demonstrate excellent patency and freedom from target vessel instability.

ABSTRACT. Objective This study aims to evaluate the mid- to long-term clinical outcomes of the E-liac (Artivion©) Iliac Branched Device (IBD) in patients undergoing endovascular iliac artery repair.

Methods This retrospective multicenter observational study included all patients treated with the E-liac (Artivion©) IBD in the participating centres between January 2011 and December 2024. Patients treated for acute ruptured aneurysm were excluded. IBD was indicated for isolated iliac aneurysm, as treatment for type 1b endoleak or in combination with EVAR for aorto-iliac aneurysm. Primary outcome was technical success, defined as deploying the IBD as planned while maintaining flow in the internal and external iliac arteries, without type 1 or 3 endoleak that extends beyond 30 days and without mortality within 30 days. A subgroup of patients with at least 60 months of follow-up was analysed separately.

Results A total of 252 E-liac IBDs were deployed in 221 patients. 171 IBDs (67.9%) required combination with EVAR, 61 cases (24.2%) were treated with IBD for isolated iliac aneurysm and 20 cases (7.9%) got an IBD extension for type 1b endoleak. Technical success was achieved in 240 cases (95.2%). Median follow-up time was 29 months (IQR13.5-60). 2 cases died within 30 days of the index procedure (1.2%). Freedom from IBD-related reintervention at 12 months was 93.5%. Sixty-four IBDs were included in the subgroup analysis of long-term follow-up. The internal iliac artery (IIA) remained patent in 63 of these cases (98.4%).

Conclusion Mid- and long-term follow-up of the E-liac IBD demonstrate its effectiveness, with high IIA patency and acceptable reintervention rate.

ABSTRACT. Objective Acute aortic syndromes (AAS) encompass acute aortic dissection (AD), intramural hematoma (IMH), and penetrating atherosclerotic ulcer (PAU). Prompt management is essential to reduce mortality. We have reviewed our single university center experience, evaluating time to treatment, therapeutic strategies and postoperative outcomes. Methods All AAS managed in our hospital between January 2021 and December 2023 were included. Traumatic and iatrogenic AAS were excluded. They were reviewed retrospectively. The analyzed parameters included age, sex ratio, origin of the transfer, type of AAS, time to diagnosis and intervention, early reinterventions, and 30-day morbidity and mortality. All types of management including open surgery, endovascular technique, as well as medical treatment, were studied. Results They were 73 cases of AAS. Type A AD accounted for 69% of cases, with a mean aortic diameter of 49 mm (30% ≤ 45 mm). Most of the patients (72%) were secondary transfers. A history of aortic disease was present in 36% of cases, including 9.7% with a second AAS. The predominant symptom was chest pain (72%). The mean time between computed tomography angiography and surgery start was 240 minutes. Cerebral malperfusion affected 28% of patients with type A AD. The 30-day operative mortality rate was 15.2% for type A AD and 24% overall. Type B AD had a mortality rate of 13%, mainly due to ischemic complications. Early reinterventions occurred in 4% of type A AD. Conclusions The volume of treated AAS positions our hospital among the most experienced belgian centers. The study highlights the importance of early detection, optimal timing, and tailored strategies to improve prognosis. Rigorous follow-up is mandatory to anticipate early and late complications.

ABSTRACT. Objective: To evaluate the outcomes of inner-branch endovascular aneurysm repair (iBEVAR) for the treatment of type Ia or III endoleak after infrarenal EVAR. Methods: This multicentre study retrospectively analyzes all consecutive patients who underwent elective revision using iBEVAR for type Ia or III endoleak after previous infrarenal EVAR. Primary outcome was technical success, defined as placement of both the main-body endograft and successful catheterization and stenting of target vessels in an intent-to-treat manner, further defined by the absence of an endoleak type I and III at the end of the procedure, absence of graft obstruction or occlusion at the end of the procedure, absence of the need to convert to open surgical repair and absence of mortality from aortic-related causes during the first 30 days after the procedure. Results: A total of 21 patients were included in the study. Time between initial EVAR and iBEVAR was median 6.7 years (IQR 4.2 – 9.8). Indication for iBEVAR was type Ia endoleak due to proximal aneurysmal degeneration after EVAR in 20 cases and type III endoleak from the EVAR main-body in 1 case. Technical success was noted in 85.7% of cases. Three patients (14.3%) died within 30 days after the index procedure. During a median follow-up of 11.0 months (IQR 2.8-22.5), 6 (28.6%) reinterventions were performed for aortic-related causes. Overall median time to reintervention was 11.0 months (IQR 4.5-11.5). Primary target vessel patency during follow-up was 96.4%. Conclusion: Treatment of type Ia and III endoleak after previous infrarenal EVAR using proximal extension with iBEVAR is safe and feasible. The technique has demonstrated acceptable technical success and high target vessel patency in this short-term analysis. It is however a technically demanding procedure and mortality is still considerable. Future research should focus on the long-term outcome and careful patient selection.

ABSTRACT. Objective: Endovascular abdominal aortic aneurysm repair (EVAR) has become a well-established procedure, even in more challenging anatomy. While short term outcomes are favorable and well documented, long-term results remain limited. This study aims to contribute additional long-term data.

Methods: This is a single-center retrospective study. The primary endpoint was long-term mortality. Secondary endpoints include the incidence of endoleak, reintervention rates and aneurysm sack morphology changes over time. The whole cohort as well as patients with a hostile neck versus patients without will be analyzed.

Results: Between 2008 and 2016, 77 patients were treated. The mean imaging follow up was 78 ± 52,4 months. Aorta anatomy between groups based on neck diameter, length, calcification and thrombus were not significantly different. Higher neck angulation and more conical features were present in the hostile group. Overall survival at 60 months was 75,3%, 51,9% at 96 months and 42,7% at 120 months. (Fig 1.) There was no significant difference in overall survival between the two groups. Only 1 aneurysm rupture occurred in the first 10 years resulting in a freedom from aneurysm rupture of 98,2% at 10 years. Diameters remained stable or decreased at 10 years in 75% of aneurysms. Secondary endoleaks were prevalent and identified in 36 (46,8%) patients. Patients with a hostile neck did not have a significantly higher rate of endoleak. Reinterventions were required in 22 (28,6%) patients; 64,9% of these secondary reinterventions were needed to treat endoleak, mostly type Ia and type II. Patients with a hostile neck did not have a significantly higher reintervention rate.

Conclusion: The long-term results for the endurant stentgraft are favorable. Aneurysm rupture is rare. A hostile neck did not lead to an increased rate of endoleak or reintervention. Higher endoleak and reintervention rates did not lead to a worse mortality outcome in this study.

ABSTRACT. OBJECTIVE Thoracic aortic pseudoaneurysm are a rare late complication of high-energy deceleration or blunt chest trauma. These lesions may remain clinically silent for years and are sometimes discovered incidentally decades after the initial injury. Due to their low incidence and heterogeneous presentation, standardized management strategies are lacking. The aim of this study is to analyze contemporary decision-making strategies for these lesions, emphasizing how lesion chronicity, anatomical constraints and patient-specific risk factors guide the choice between conservative, open, endovascular or hybrid approaches. METHODS A focused literature review on chronic post-traumatic thoracic aortic pseudoaneurysms was performed to identify key elements influencing therapeutic decision-making, including anatomical location, involvement of supra-aortic branches, symptomatology and patient related factors. These principles were applied to a representative complex clinical case to demonstrate a structured, multidisciplinary approach to selecting an optimal treatment strategy. RESULTS A 33-year-old female presented with chest pain and left upper-limb paresthesia 14 years after a ski accident. Diagnostic workup revealed a chronic pseudoaneurysm of the aortic isthmus originating at the root of the left subclavian artery, measuring around 5x5 cm. Given the young age, symptomatic presentation and challenging location of the lesion, isolated open repair or endovascular aortic repair alone were considered suboptimal. Multidisciplinary evaluation, guided by predefined clinical and anatomical criteria, led to selection of a single-stage hybrid strategy. This included open supra-aortic debranching with bypass of the left carotid and subclavian arteries to the ascending aorta, followed by endovascular stent-grafting of the aortic isthmus and descending thoracic aorta. The perioperative course was uneventful with no neurological or vascular complications. CONCLUSIONS Management of chronic post-traumatic thoracic aortic pseudoaneurysms require individualized, anatomy-driven decision-making. Hybrid open-endovascular repair is a safe and effective option for patients with complex anatomy and may serve as a model for applying structured treatment strategies in similar cases.

ABSTRACT. Background

Loeys–Dietz syndrome (LDS) is a heritable thoracic aortic disease associated with aggressive vascular phenotypes, including early-onset aortic dissections occurring at small diameters. Women, particularly during pregnancy and the postpartum period, are at increased risk. Optimal surgical management remains challenging and poorly documented.

Methods

We report a monocentric retrospective case series of three young women with genetically confirmed LDS who presented with Stanford type B aortic dissections. Clinical presentation, imaging findings, surgical strategies, perioperative outcomes, and mid-term follow-up were analyzed, with a specific focus on staged and hybrid aortic repair.

Results

All patients were young women (27–37 years), including one presenting during the third trimester of pregnancy. Dissections occurred spontaneously and at relatively small aortic diameters. Initial management required urgent intervention in all cases due to pain recurrence, malperfusion, or visceral ischemia. Surgical strategies included thoracic endovascular aortic repair (TEVAR) as a life-saving or bridging procedure, followed by complex staged repairs combining hybrid and open techniques, such as frozen elephant trunk procedures, extensive thoracoabdominal aortic replacement, and valve-sparing aortic root replacement. Postoperative morbidity was significant but manageable, including respiratory failure, renal impairment, and sepsis in one patient. There was no perioperative mortality. Mid-term clinical and radiological follow-up demonstrated satisfactory aortic remodeling and favorable outcomes.

Conclusions

Aortic dissections in women with Loeys–Dietz syndrome are characterized by early presentation and aggressive evolution. Surgical management frequently requires individualized, staged strategies combining endovascular, hybrid, and open repairs. TEVAR plays a valuable role in emergency settings but should be integrated into a comprehensive long-term surgical plan. Early genetic diagnosis and multidisciplinary management in specialized aortic centers are essential to optimize outcomes.

ABSTRACT. OBJECTIVE: Open surgical repair of aortic arch pseudoaneurysms carries substantial morbidity and mortality, particularly in patients with prior extensive thoracic surgery and significant comorbidities. The objective of this report is to describe the feasibility and early outcome of a hybrid aortic arch repair using a custom-made single-branched thoracic endograft in a patient deemed unsuitable for conventional open surgery. METHODS: A 48-year-old man with a history of left pneumonectomy and chest wall resection for lung cancer was diagnosed with an aortic arch pseudoaneurysm during routine follow-up imaging. Due to a hostile mediastinum and associated coronary artery disease, open repair was contraindicated. A hybrid approach was performed, consisting of a right-to-left carotid–carotid bypass for cerebral revascularization, followed by implantation of a custom-made single-branched thoracic endograft with a proximal landing zone in aortic arch zone 0 and branch alignment to the brachiocephalic trunk. Rapid ventricular pacing was used to facilitate accurate endograft deployment. RESULTS: The procedure was technically successful. Completion angiography demonstrated correct endograft positioning, patency of the side branch and carotid–carotid bypass, and complete exclusion of the pseudoaneurysm without endoleak. No perioperative neurological complications occurred. Postoperatively, the patient developed acute myocardial ischemia requiring percutaneous coronary intervention, with full recovery. One-month follow-up computed tomography angiography confirmed durable pseudoaneurysm exclusion and excellent graft patency. CONCLUSIONS: Hybrid aortic arch repair using a custom-made single-branched thoracic endograft with zone 0 landing is a feasible and effective treatment option for selected high-risk patients with complex surgical history. This approach may offer a safe alternative to open repair when conventional surgery is contraindicated.

ABSTRACT. Background: Endovascular management of femoropopliteal peripheral arterial disease (PAD) remains challenging, particularly in calcified and complex lesions. Atherectomy combined with drug-coated balloons (DCB) has emerged as a promising strategy to improve luminal gain, drug uptake, and procedural outcomes. This study reports our early single-center experience using Jetstream rotational atherectomy followed by DCB angioplasty for femoropopliteal lesions. Methods: We conducted a retrospective analysis of consecutive patients treated at our institution in Brussels between January 2022 and January 2026. A total of 20 patients presenting with symptomatic femoropopliteal PAD were included. Most lesions were calcified or of mixed morphology. The intervention consisted of Jetstream atherectomy for plaque debulking, followed by DCB angioplasty, with provisional stenting when necessary. Clinical follow-up was performed at 1, 3, 6, and 12 months. Primary endpoints included technical success and clinical improvement assessed by Fontaine–Leriche stage. Secondary endpoints included procedural complications and need for bailout stenting. Results: Technical success was achieved in 95% of cases, One technical failure occurred due to inability to cross the lesion with a guidewire.At follow-up, 84 % of patients demonstrated improvement in Fontaine–Leriche stage. two patients failed to demonstrate Fontaine–Leriche stage class improvement and subsequently required major limb amputation several weeks after the procedure and one patient continued to experience intermittent claudication despite technical procedural success.Mean follow-up ranged from 3 to 12 months. One access-site pseudoaneurysm occurred and was managed without long-term sequelae, no additional procedure-related complications were observed, and Bailout stenting was required in one patient due to flow-limiting dissection. Conclusion: Endovascular treatment of Femoropopliteal Lesions using atherectomy combined with drug-coated balloon angioplasty appears feasible and safe. This approach allows treatment across all Azéma classification types while avoiding potential complications associated with open surgical repair. Furthermore, the “leave nothing behind” strategy eliminates the need for permanent implants, preserving future treatment options.

ABSTRACT. Background: Supervised and structured exercise therapy (SET) is a cornerstone of guideline-recommended management of lower-extremity arterial disease (LEAD), yet its implementation varies widely across clinical settings. This study assessed current practices, perceptions, and barriers related to walking therapy and exercise therapy among vascular clinicians in Belgium.

Methods: A survey was distributed electronically to all 230 members of the Belgian Society for Vascular Surgery (BSVS). Forty-seven clinicians completed the questionnaire (response rate 20.4%). The survey assessed practice patterns in management of claudication, use and accessibility of structured exercise programs, and attitudes toward SET. Data were analyzed descriptively.

Results: Respondents reported seeing a median of 20 LEAD patients per week (range 5–80). Initial management varied: 23.4% treated most (>75%) of new claudicants conservatively, whereas 21.3% treated >75% surgically. Functional limitation (87.2%) and short walking distance (74.5%) were the most frequent motivations for primary intervention. Conservative management commonly consisted of verbal walking advice (74,5%); specific physiotherapist-guided walking therapy was offered less often (23.4%). Structured exercise programs were rarely used: 58,9% never used them and accessibility was considered low (65,9% did not know where or how to refer). Despite this, 83% believed in the added value of structured or supervised exercise therapy, and 83% would refer patients if an accessible program were more easily available.

Conclusion: Although Belgian vascular clinicians broadly acknowledge the value of structured exercise therapy for LEAD, implementation is limited by practical barriers, including poor accessibility, uncertainty about referral pathways, and lack of structured programs. Improving referral infrastructure and increasing availability of supervised exercise therapy could substantially enhance conservative management of claudication in Belgium.

ABSTRACT. OBJECTIVE Endovascular treatment of femoropopliteal artery disease remains challenging, particularly in calcified and mechanically stressed vessels. Interwoven nitinol stents were developed to improve durability, whereas atherectomy combined with drug coated balloon angioplasty follows a leave-nothing-behind strategy. This study aimed to compare these two approaches in symptomatic femoropopliteal artery disease, with one-year primary patency as the main outcome.

METHODS We retrospectively analyzed 70 de novo femoropopliteal lesions treated between 2015 and 2017. Thirty-five lesions were treated with an interwoven nitinol stent and 35 with atherectomy followed by drug coated balloon angioplasty. All patients were symptomatic and had at least one patent below-the-knee runoff vessel. Short or long lesions, prior interventions, critical limb ischemia, and inadequate inflow or outflow were excluded. Follow-up included duplex ultrasound and clinical assessment at 1 month, 12 months, and annually thereafter. Primary patency, restenosis, reocclusion, target lesion revascularization, and mortality were evaluated.

RESULTS At 12 months, primary patency rates were similar between the interwoven nitinol stent and atherectomy groups (82.9% vs. 89.3%, p = 0.72). Restenosis occurred more frequently after stent implantation (54.5% vs. 14.3%, p = 0.001). Reocclusion rates tended to be higher in the stent group (31.5% vs. 10.7%, p = 0.06). Target lesion revascularization rates were comparable (6.1% vs. 7.1%, p = 1.00). Mortality during follow-up did not differ significantly between groups (14.3% vs. 11.4%, p = 1.00). Lesions treated with stents were more frequently severely calcified.

CONCLUSIONS Both strategies achieved comparable one-year primary patency. However, atherectomy combined with drug coated balloon angioplasty was associated with significantly lower restenosis rates, particularly in heavily calcified lesions. These findings suggest that atherectomy with drug coated balloon angioplasty may offer advantages in the treatment of complex femoropopliteal artery disease.

ABSTRACT. Objective: In this study we evaluate whether the rising incidence of PAES in our centre reflects an actual increase in prevalence or a trend toward clinical overdiagnosis. Methods: All patients diagnosed with PAES in our hospital between January 2019 and March 2025 were included in the study. Diagnosis was made on the positive triad of suggestive symptoms, decreased ankle-brachial index (ABI) and compression on CT or MR angiography. Conservative and operative treatments were proposed and discussed with all patients. Retrospective analysis of demographic, clinical, and surgical data was performed. Results: Thirty-two patients were diagnosed with PAES with a total of 57 affected legs. Thirty-five legs in 21 patients underwent surgical decompression. Functional success was achieved in 60.0% and technical success in 85.7% of the operated legs. Positive evolution in the ABI is seen with prolonged follow up. Fourteen legs experienced no functional improvement after surgery, despite evidence of technical success in nine legs (25.7%). Five patients were postoperatively diagnosed with other causal pathologies than PAES and two patients experienced symptom relieve with botulinum toxin infiltration postoperatively. Conclusion: PAES is a pathology with a broad differential diagnosis and a risk of overtreatment. The difference between postoperative functional and technical success indicates that other pathologies may be responsible for the patient’s symptoms and that the popliteal compression may be an asymptomatic coincidence. PAES should be considered a diagnosis of exclusion in a multidisciplinary setting when the triad of suggestive symptoms, decreased ABI, and compression on CT or MR angiography is present, to maximize the postoperative functional success. To determine technical success, prolonged ABI follow-up is recommended, as improvement may occur over time.

ABSTRACT. Objectives Carotid artery infections are rare and may be due to mycotic aneurysms, stent or patch infections following carotid endarterectomy. This case series describes the multidisciplinary management of a potentially life-threatening problem. Methods Three patients presented with carotid artery infection at a single institution. All were discussed at a multidisciplinary team meeting. Patients were informed about risks associated with surgical repair. All patients were examined by an independent neurologist pre and postoperatively. Results Clinical manifestations in these three patients consisted of cervical pain and fever without neurological complications. The three patients agreed to surgery. One man (65yrs) had a mycotic carotid aneurysm due to Streptococcus dysgalactiae, confirmed by blood cultures and PCR, and underwent resection with autologous vein interposition. Intravenous ceftriaxone was administered for 12 weeks due to additional infectious sites. The second patient (man 67 yrs) presented with recurrent MSSA bacteremia due to an infected carotid stent, fulfilling major and minor MAGIC criteria (infected implant, PET-CT FDG uptake, positive blood cultures). Following stent explantation and venous reconstruction, 6 weeks of IV flucloxacillin followed by oral suppressive therapy were given. The last patient, a woman (87 yrs) had an exposed infected carotid patch, fulfilling major MAGIC criteria, treated by patch removal and venous reconstruction with 6 weeks of culture-guided antibiotics. No perioperative or postoperative neurological or vascular complications occured. Follow up ranged from 6 weeks until 6 months. No recurrent infection was detected during follow up. Conclusion This small case series highlights that aggressive surgical management with complete excision of infected tissue and foreign material, followed by autologous venous reconstruction and prolonged targeted antibiotic therapy, leads to good clinical outcomes. A multidisciplinary individualized patient approach is the cornerstone of treating infected carotid diseased to achieve durable outcomes while minimizing neurological complications.

ABSTRACT. Background: Aberrant right subclavian artery or arteria lusoria is a rare developmental anomaly of the aortic arch, where the origin of the artery is in the descending aorta. With a prevalence of 0.5-1%, it is one of the most common variants of the aortic arch. Most patients are asymptomatic, but approximately 10% will develop dysphagia or dyspnea due to compression on the esophagus or the trachea, depending on the course of the artery. Case presentation: We present the case of a 48-year-old woman referred for a persistent sensation of pressure and pain at the base of the throat coupled with dysphagia. A barium esophagogram showed compression of the esophagus, likely due to an arteria lusoria. Computed tomography scan of the aortic arch confirmed the diagnosis and showed the absence of other congenital anomalies, such as Kommerell’s diverticulum. A hybrid procedure was performed, consisting of a right carotid-subclavian bypass with dacron prothesis through supraclavicular incision, followed by resection of the intrathoracal part of the subclavian artery through robot assisted thoracoscopy. The patient recovered well with complete resolution of her symptoms immediately after surgery and was discharged after 5 days. Discussion: Reported surgical procedures for aberrant right subclavian artery range from open and extensive cardiosurgical procedures with reimplantation of the subclavian artery or replacement of the descending aorta to newer hybrid endovascular procedures with TEVAR stenting. This case shows an alternative approach with carotid-subclavian bypass followed by minimally invasive resection of the intrathoracic segment of the artery. Due to the rarity of this condition no large randomized controlled trials have been performed and no society guidelines are available. We recommend a multidisciplinary evaluation of these patients to select a tailored approach with minimal morbidity.