To determine the uptake of robotic-assisted bariatric surgery and evaluate its safety compared to the laparoscopic approach. Use of the robotic-assisted platform for bariatric surgery is increasing, however its comparative safety relative to the laparoscopic approach is unclear. This retrospective cohort study included adult patients in a national Medicare claims database who underwent bariatric surgery from January 1, 2012 to December 31, 2020. Instrumental variables analysis was used to assess risk-adjusted outcomes at 90 days, and 1, 3, 5, and 7 years after surgery. 121,521 patients (mean [SD] age 56.9 [11.7] years; 91,136 [75.0%] female) underwent bariatric surgery during the study period, of whom 74,993 (61.7%) underwent sleeve gastrectomy and 46,528 (38.3%) underwent gastric bypass. Use of robotic-assisted sleeve gastrectomy increased by 250%, from 5.1% to 17.9%, and use of robotic-assisted gastric bypass increased by 361%, from 4.2% to 19.3%. There were no significant differences in 90-day outcomes between the two approaches. At 7 years, there were no significant differences in the adjusted hazard ratio (aHR) of complications, hospitalization, emergency department use, reintervention, or revision between the two approaches. However, compared to the laparoscopic approach, the robotic-assisted approach was associated with a higher 7-year aHR of reoperation for both procedures (sleeve gastrectomy aHR 1.51 [95% CI 1.06-1.97]; gastric bypass aHR 1.58 [95% CI 1.12-2.03]). In this national cohort, use of robotic-assisted bariatric surgery more than tripled over the last decade, and short- and long-term outcomes were largely equivalent.

We aimed to evaluate the impact of an electronic health record (EHR)-based default "nudge" intervention on opioid prescribing after common surgical operations. Given ongoing national challenges in opioid use and opioid-related adverse events, there is a need to optimize opioid prescribing after surgery. Behavioral nudges built into the EHR may be effective and useful, but they have not been widely tested among surgeons. This is a randomized clinical trial at a large academic medical center involving adult surgical patients. System-wide, 118 surgical clinicians were randomized to control or intervention versions of an electronic discharge order set; the intervention arm had suggested pre-populated opioid and adjunct prescriptions. The outcome was morphine milligram equivalents (MME) prescribed at discharge, analyzed at the surgical encounter level. 663 surgical encounters (377 intervention and 286 control) were analyzed. 57% of the patients were female, and the median age was 49 years. The most common operations were laparoscopic cholecystectomy (39%), laparoscopic appendectomy (25%), and laparoscopic/robotic colectomy (12%). The median opioids prescribed at discharge was 75 MME (~ 10 oxycodone-5mg tablets). Overall, in the intention-to-treat analysis, there were similar MME prescribed in the control and intervention groups (adjusted difference: 2.4 MME, 95% CI: -14.7 to 19.4, P=0.79). Only 21% in the intervention group received prescriptions from pre-populated defaults, while 79% received free form prescriptions. In as-treated analysis, the pre-populated prescriptions were substantially smaller than those written free form (adjusted difference: -22.5 MME, 95% CI: -34.7 to -10.2). The offering of pre-populated opioid prescriptions to surgeons did not reduce postoperative opioid prescribing overall. However, the subset of surgeons who accepted the defaults prescribed much less opioids. Default nudge interventions may be useful in optimizing opioid prescribing, but stronger versions of defaults and co-interventions are likely needed.

Primary objective was to evaluate the association between post-surgical MRD detected by a tumor-informed personalized panel (brPROPHET) and CRC recurrence, Secondary objectives were to determine the optimal timepoint for MRD assessment, and compare the performance of different MRD detection methods, including brPROPHET, a tumor-informed fixed panel (TIFP) and a tumor-naïve fixed panel (TNFP). Circulating tumor DNA (ctDNA)-based molecular residual disease (MRD) has emerged as a pivotal marker in colorectal cancer (CRC), but optimal detection timing and methods remain unclear. This study included patients with resectable stage I-IV CRC. Tumor tissues were obtained at surgery, and blood samples were collected preoperatively, on post-surgical days 7 and 30 (D7/D30), and every 3-6 months. MRD was assessed using the above three methods. A total of 214 patients were included in the analysis, with imaging follow-up available for 196 patients (median follow-up: 18.2 months), among whom 24 (12.2%) experienced recurrence. MRD positivity at D7/D30 associated with significantly reduced disease-free survival (DFS). Longitudinal ctDNA-MRD positivity and MTM levels >0.01/mL were also associated with recurrence. Adjuvant chemotherapy was associated with better DFS in patients with positive MRD at D7 (HR=0.26, 95% CI 0.07-0.98, P=0.03) instead of those with negative MRD at D7. Among the 168 patients assessed with all three methods, the brPROPHET assay demonstrated better association of DFS at D7. ctDNA-based MRD detected by brPROPHET associates with recurrence in CRC. Day 7 is an effective alternative landmark to Day 30 for MRD assessment and brPROPHET outperforms TIFP and TNFP in the association of DFS. ClinicalTrials.gov number: NCT06143644.

To evaluate the learning curve for robotic liver resection (RLR) in France and determine the impact of procedural frequency on surgical performance (conversion) and postoperative outcomes (complications). RLR is increasingly adopted for its ergonomic and technical advantages. However, proficiency in RLR is primarily limited by restricted access to robotic platforms, which hinders consistent case exposure and learning. Understanding how procedural frequency influences learning and outcomes is critical for optimizing training and implementation. This retrospective multicenter cohort study (FRIES-ACHBPT-2024) included 650 patients who underwent RLR across 10 French hepatobiliary centers (2010-2024). Learning curves were analyzed using cumulative sum (CUSUM) analysis for conversion and blood loss, stratified by procedural complexity (IMM grades 1-3) and recurrence interval (high-frequency: ≤7 days; low-frequency: >7 days). Multivariable logistic regression identified independent predictors of postoperative complications. The conversion rate was 10.8%. Blood loss increased with IMM grade (184mL for IMM 1, 381mL for IMM 2, and 753mL for IMM 3). Learning curve inflection points were reached at 41 cases for conversion and 58 for blood loss. Surgeons with high-frequency access achieved competency earlier (35 vs. 47 cases). Independent predictors of postoperative complications included low-frequency access, age >70, metabolic syndrome, tumor size >5cm, high IMM grade, and conversion. Frequent access to robotic platforms (at least once a week) facilitates earlier proficiency in RLR and reduces complication risk. Structured training pathways and equitable access are essential to safe and effective RLR adoption.

To evaluate the role of SMAD4 mutational status on clinical outcomes in patients with localized pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant chemotherapy (NAC). NAC is increasingly utilized in the management of localized PDAC. In biologically unselected patients, FOLFIRINOX (FFX) and gemcitabine plus nab-paclitaxel (gem/nab-p) demonstrate equivalent oncologic outcomes. SMAD4 has been identified as a potential biomarker of resistance to FFX in single institution studies but validation is needed. A multicenter, retrospective cohort study was conducted of patients with localized PDAC who received neoadjuvant FFX or gem/nab-p. Alterations in SMAD4 were assessed by targeted next-generation sequencing. The association of SMAD4 alterations with rates of metastatic progression and surgical resection were assessed by multivariable logistic regression accounting for resectability status and tumor location. The rate of SMAD4 alterations was 27.3% (85/311). A total of 168 (54.0%) patients underwent surgical resection; there was no difference in rates of surgical resection between FFX vs. gem/nab-p treatment groups (52.0% vs. 59.3%; P =0.248). When stratified by SMAD4 mutational status, SMAD4 alterations were associated with increased likelihood of metastatic progression (OR 1.89, 95% CI 1.01-3.55; P =0.047) and failure to complete surgical resection (OR 0.49, 95% CI 0.26-0.91; P =0.024) uniquely among patients who received FFX. SMAD4 alterations were not associated with metastatic progression ( P =0.804) or surgical resection ( P =0.689) for gem/nab-p treated patients. Alterations in SMAD4 were predictive of treatment failure for patients receiving neoadjuvant FFX. These data warrant prospective evaluation and support future trial designs incorporating SMAD4 as a predictive genomic biomarker.