General Surgery — Weekly Evidence Brief

Minimally invasive surgical approaches are demonstrating broad advantages in various abdominal procedures. Robotic-assisted surgery (RAS) significantly reduces the odds of conversion to open surgery compared to laparoscopy across 15 diverse abdominal procedures, regardless of patient age, BMI, or sex 1. This benefit extends to complex cases, as robotic surgery for early-stage endometrial cancer is safe and effective across all BMI ranges, including Class III obesity, with comparable console time, hospital stay, and complication rates 2. Furthermore, laparoscopic distal gastrectomy with D2 lymphadenectomy for clinical T4a gastric cancer shows equivalent 30-day morbidity and mortality to open surgery, despite longer operative times and higher blood loss 3. In metastatic renal cell carcinoma with tumor thrombus, open, laparoscopic, and robotic approaches for cytoreductive nephrectomy with tumor thrombectomy demonstrate no significant differences in oncologic outcomes 4.

Optimizing treatment strategies for various cancers is evolving with new evidence. Organ preservation strategies in esophageal cancer, such as definitive chemoradiotherapy or active surveillance post-neoadjuvant chemoradiotherapy, are viable alternatives to esophagectomy, offering comparable 5-year overall survival and significantly enhanced quality of life 5. For microsatellite instability-high (MSI-H) colon cancer with isolated peritoneal metastases, combining immunotherapy with surgical resection of the primary tumor significantly improves overall survival compared to chemotherapy alone 6. Surgery is also independently associated with improved overall survival in locally advanced vulvar cancer, underscoring its crucial role 7. However, real-world data indicate that the use of perioperative treatments for resectable gastric and gastroesophageal junction cancer in the US is lower than expected, correlating with persistently poor long-term outcomes 8.

Advanced prognostic tools and international reference values are refining risk stratification in surgical oncology. New international reference values for total pancreatectomy outcomes highlight increased perioperative risks for patients with vascular resections or high-risk anastomosis, crucial for quality control and patient counseling 9. For complex major hepatectomy combined with pancreatoduodenectomy, a remnant liver functional reserve to body weight (FLR/BW) ratio of <0.8% independently predicts significantly increased mortality (14%) 10. In inoperable pancreatic cancer, a combined clinical-radiomics nomogram offers superior personalized prognostic prediction (C-index 0.892) for patients undergoing concurrent chemoradiotherapy 11. Similarly, for unresectable hepatocellular carcinoma, a multimodal deep learning model (TRIM-uHCC) provides significantly more accurate individualized prognostic stratification than current guideline-based systems, aiding treatment decisions 12.

Postoperative recovery and complication management are being enhanced through prehabilitation and a nuanced understanding of patient factors. Personalized prehabilitation before major surgery significantly improves physical function and reduces moderate-to-severe postoperative complications, demonstrating profound immune modulation and a biological rationale for improved surgical readiness 13. The impact of Body Mass Index (BMI) on postoperative recovery to independent living follows a U-shaped relationship, with underweight and severely obese patients facing significantly higher risks of adverse discharge, while overweight and mildly obese individuals show reduced risks 14. For recurrent weight gain after sleeve gastrectomy, endoscopic revision offers comparable weight loss efficacy with a significantly better safety profile (0% vs 11% serious adverse events) and shorter hospital stays compared to surgical revision 15. However, traditional tools like the P-POSSUM scale prove inadequate for predicting morbidity in ovarian cancer cytoreductive surgery, necessitating improved risk assessment models 16.