General Surgery — Weekly Evidence Brief

Neoadjuvant therapy (NAT) is increasingly vital in managing various aggressive cancers, often proving safe and effective. For borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC), NAT followed by pancreatectomy yields survival outcomes comparable to primary resectable pancreatic cancer, with acceptable postoperative morbidity and good quality of life recovery 1. Similarly, neoadjuvant chemotherapy (NACT) before gastrectomy for gastric cancer (GC) does not increase postoperative morbidity or mortality in selected patients, especially when using the FLOT regimen, which is associated with lower complication rates 2. In locally advanced esophageal squamous carcinoma (LA-ESCC), a nomogram can stratify patients after neoadjuvant immunochemotherapy (NICT), identifying a high-risk group that significantly benefits from postoperative adjuvant therapy 3. For gastro-esophageal cancer, FLOT-immunotherapy regimens show superior event-free survival compared to FLOT-only or cisplatin/fluoropyrimidine-immunotherapy regimens 4.

Postoperative complications can significantly affect patient outcomes. Anastomotic leak (AL) following gastrectomy, occurring in 2.9% of patients, not only increases short-term morbidity but also significantly reduces long-term overall survival, particularly within the first four years post-surgery 5. Chyle leak (CL) after pancreaticoduodenectomy for pancreatic head cancer, affecting 13.8% of patients, is associated with prolonged hospital stays and poor nutritional status at discharge. However, CL does not appear to significantly impact long-term oncologic outcomes or delay adjuvant chemotherapy 6. Despite concerns about neoadjuvant therapies impacting surgical safety, the incidence of major surgical complications (Clavien-Dindo grade >3) was similar between FOLFIRINOX and gemcitabine-based chemoradiotherapy in patients with (borderline) resectable pancreatic cancer 7.

Technological advancements and optimized care delivery models continue to reshape surgical practice. Robotic-assisted radical cystectomy (RARC) implementation, even in centers new to the procedure but experienced in open radical cystectomy and other robot-assisted surgeries, demonstrated significantly shorter operative times, hospital stays, lower estimated blood loss, and fewer overall postoperative complications compared to open radical cystectomy (ORC) 8. While the overall superiority of robot-assisted surgery (RAS) over laparoscopy in colorectal surgery remains inconclusive, RAS may offer advantages in selected complex procedures, with emerging evidence suggesting improved short-term outcomes and even enhanced oncological outcomes in rectal cancer 9. Beyond individual procedures, centralizing complex surgical care across multi-hospital systems has consistently shown improved clinical outcomes, including mortality and complication rates, and more efficient resource utilization 10.

Identifying reliable prognostic factors and developing accurate prediction tools are crucial for personalized cancer management. For resected biliary tract cancers, established factors like ECOG performance status, resection margin, lymph node involvement, and CA19-9 levels are significant prognostic indicators for overall survival 11. Adjuvant chemotherapy for resected biliary tract cancers did not significantly improve overall survival in the overall cohort, though potential benefits were seen in intrahepatic and extrahepatic cholangiocarcinoma subgroups 11. In initially unresectable hepatocellular carcinoma (uHCC) undergoing conversion hepatectomy after lenvatinib, PD-1 inhibitor, and interventional therapy, novel nomograms accurately predict tumor recurrence and recurrence-free survival, outperforming traditional staging systems 12. These nomograms incorporate factors such as tumor number, differentiation, and preoperative systemic immune-inflammation index, providing valuable tools for risk stratification and tailored treatment 12.