Malignant peritoneal mesothelioma (MPM) is a rare and aggressive tumour with poor prognosis, often diagnosed late due to nonspecific symptoms. Current standard treatment involves systemic chemotherapy and cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), but this approach is limited to selected patients. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) has emerged as a novel technique improving drug delivery and penetration in the peritoneal cavity. This narrative review evaluates the role of PIPAC in the treatment of MPM, analysing data from clinical studies on its feasibility, safety, and efficacy. Evidence suggests that PIPAC is a well-tolerated procedure, with a manageable safety profile and potential to improve survival and tumour response in patients with unresectable or recurrent disease. Limitations in current studies include small cohorts and heterogeneous patient populations, underscoring the need for further research. PIPAC represents a promising therapeutic option, offering enhanced intraperitoneal chemotherapy (IPC) delivery with minimal systemic toxicity. Future investigations should focus on optimizing treatment protocols and evaluating long-term benefits to better define PIPAC's role in clinical practice.

Non-operative management (NOM) of complicated appendicitis is increasingly accepted, but the role of interval appendicectomy (IA) remains contentious. Contemporary evidence has shifted decision-making from recurrence risk alone toward age-linked neoplasm risk and radiological features. To synthesise contemporary randomised trials, prospective cohorts, and meta-analyses on recurrence after NOM of periappendiceal abscess, appendiceal tumour prevalence, and the diagnostic performance and harms of surveillance strategies (cross-sectional imaging and colonoscopy), to inform a pragmatic risk-stratified framework. Recurrence after successful NOM is commonly reported at 12-24% and is concentrated within the first six months. In adults presenting with periappendiceal abscess, appendiceal tumour prevalence rises with age, reaching approximately 5-10% in patients aged 35-39 and 14-20% in cohorts of patients aged ≥40 years. Interval CT/MRI findings identify higher-risk patients in whom IA should be prioritised. Colonoscopy is best used selectively, particularly when caecal pathology is suspected, imaging is equivocal, or IA is not planned in older patients. Interval appendicectomy should generally be considered for patients aged ≥40 years and for any patient with persistent symptoms or concerning radiological findings, while recognising that decisions must be individualised with shared decision making. Younger patients with complete radiological resolution and no red-flag features can usually be observed with structured imaging follow-up. A risk-stratified clinical algorithm is proposed to guide post-NOM management.

The article "Are There Any Differences in Clinical Outcome after the Surgical Management of Patients with Stomach versus Duodenal Perforation?" [Dig Surg 2025;42:220-228; https://doi.org/10.1159/000547869] by Lahes et al. was published with the wrong open access license. The correct license of the article is CC-BY.The original article has been updated.

Non-occlusive mesenteric ischemia (NOMI) is a rare but lethal complication after gastric cancer (GC) surgery, marked by intestinal hypoperfusion without arterial occlusion. Nonspecific symptoms and rapid deterioration hinder timely diagnosis. This study evaluated outcomes, diagnostic pathways, and management. We retrospectively reviewed eight GC patients who developed NOMI (February 2022-January 2024). Collected variables included demographics, surgical details, feeding practices, presentation, imaging, treatment, and outcomes. The primary endpoint was 30-day mortality. NOMI presented a median of 3 days postoperatively (range 2-5). Median age was 63.5 years; 75% were male; all had advanced GC and 62.5% had gastric outlet obstruction. Common signs were abdominal distension (75%), hypotension (50%), and peritonitis (25%). CT consistently showed small-bowel dilatation, pneumatosis intestinalis, and portal venous gas, mainly in distal jejunum/ileum. Seven patients underwent re-exploration: five required resection. After implementing a modified feeding protocol, cases reduced from seven to one. Thirty-day mortality was 50%, largely from sepsis and multiorgan dysfunction syndrome (MODS). In GC patients with feeding jejunostomy, NOMI remains a serious complication. A cautious feeding strategy-deferring feeds during vasopressor support, initiating low-strength kitchen feeds, slow escalation, and early oral intake-was associated with fewer cases. High clinical suspicion, rapid CT, and timely surgery are critical to improve outcomes.

Introduction: Acute appendicitis is a common surgical emergency. Laparoscopic appendicectomy is preferred for faster recovery and less pain, but conversion to open surgery remains necessary in some cases. Most evidence on conversion comes from high-income countries, while data from low- and middle-income settings (LMIC), where resource limitations may influence surgical decisions, are scarce. This study aimed to identify factors associated with conversion in a public, resource-limited Peruvian hospital. Methods: We conducted a retrospective cross-sectional study of patients undergoing laparoscopic appendicectomy at a public hospital in Lima, Peru, between 2022 and 2023. Variables were compared between patients requiring conversion and those completing the procedure laparoscopically. Multivariate analyses were performed to identify risk factors. Results: A total of 523 patients were included. Conversion to open appendicectomy occurred in 4 patients (0.76%), primarily due to difficult dissection from severe adhesions, intraoperative hemorrhage associated with equipment malfunction. Multivariate analysis identified adhesions (OR = 8.91, 95% CI: 1.48–53.42, p = 0.017), appendicolith (OR = 11.49, 95% CI: 1.74–75.69, p = 0.001), and intraoperative complications (OR = 45.74, 95% CI: 6.71–311.55, p < 0.001) as significant factors of conversion. Conclusions: Laparoscopic appendicectomy is safe and effective in public hospitals, even in low-resource settings. Conversion was rare and mainly driven by adhesions, appendicoliths, or intraoperative complications. These findings reinforce that laparoscopic appendicectomy can be reliably performed in LMIC.

Background: The incidence of esophageal adenocarcinoma (EAC) has risen significantly in recent decades, with Barrett’s esophagus (BE) as the most important precursor. When a visible lesion is identified within BE, endoscopic resection (ER) is the preferred treatment, providing both histologic staging and curative therapy for dysplasia and low-risk EAC. Summary: Two ER techniques are commonly used: cap-based endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR is an extensively studied technique considered safe, effective, and easy to learn. However, due to the cap-based approach, lesions larger than 15–20 mm need to be removed by multiple adjacent resections, so-called piecemeal resection. This may result in remnant tissue in the resection field and may compromise histopathological assessment. In contrast, ESD enables en bloc removal regardless of lesion size. While ESD has also demonstrated safety and efficacy, it is technically more demanding and associated with longer procedure times. For some lesions, there is general agreement on treatment, with ESD preferred for lesions with suspected submucosal invasion, bulky morphology, or fibrosis. Conversely, EMR remains the standard for smaller, superficial lesions without these features. Key Message: A significant grey zone persists, clinical scenarios for which comparative evidence is lacking and consensus on the optimal treatment approach remains unclear.

Introduction: The indications for resection of intraductal papillary mucinous neoplasms (IPMNs) have been optimized according to the high-risk stigmata (HRS) and worrisome features (WFs). However, the proportion of resected IPMNs diagnosed as low grade is not insignificant. This study aimed to investigate whether fibrinogen-to-albumin ratio (FAR) improves the diagnostic ability of high-grade dysplasia (HGD) or invasive carcinoma (IC) in IPMN. Methods: This study included 47 patients who underwent surgery between April 2008 and July 2024. Clinical factors were examined to determine HGD or IC. We also compared the accuracy of predicting HGD or IC between HRS alone and HRS plus FAR. Results: A total of 23 were diagnosed with HGD or IC based on pathological diagnosis. On multivariable analysis, contrasted walled nodules ≥5 mm and FAR ≥0.0833 were significant predictors of HGD or IC. Moreover, the HRS and high FAR (≥0.0833) group had better the positive predictive value and diagnostic accuracy rate. Conclusions: FAR may be a significant predictor of HGD or IC in IPMN. In addition, when combined with HRS, its diagnostic ability as a predictor of HGD or IC may be further improved.

Introduction: Anatomical resection of tumor in liver segment S7 is the most technically challenging procedure in laparoscopic liver hepatectomy due to its deep location and complex vascular structures, which results in a steep learning curve for beginners. We explored a simple and feasible approach: a dorsal approach combined with a dorsoventral method for liver segment S7 resection. Methods: The key innovations we propose through the dorsal approach combined with a dorsoventral method include the following: (1) systematic dissection of the S7 hepatic pedicle through Rouviere’s sulcus; (2) parenchymal transection guided by the dorsal ischemic demarcation line of segment S7; (3) advance along the right hepatic vein toward the ventral aspect of segment S7. By decomposing complex maneuvers into three standardized steps (steps 1–3), this protocol significantly reduces technical barriers. The procedural details are meticulously demonstrated in this report to enhance reproducibility. Results: In the preliminary phase of this study, 20 patients were included. All patients underwent surgery smoothly, with no conversion to open surgery and no deaths, and all patients achieved R0 resection. The operation time was 190.0 (178.0–210.0) min, and intraoperative blood loss was 200.0 (150.0–280.0) mL. Conclusions: This method standardizes the laparoscopic S7 segment resection, which, while ensuring precise removal, is expected to reduce the learning curve for surgeons.

Background: The management of locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) now relies on an integrated, multidimensional assessment that goes beyond just the relationship of the tumour to vascular anatomy. Summary: By combining dynamic imaging, biomarker monitoring, genetic profiling, and thorough physiological evaluation, clinicians can more accurately select patients who are most likely to benefit from aggressive surgical intervention. These patients can then be offered NAT, singly or in combination, and preferably within the context of a clinical trial. The re-staging of patients post-NAT remains a challenge, but in patients who have shown no evidence of tumour growth or metastases and preferably with evidence of biochemical, metabolic, or radiological response and are fit enough, a trial dissection may be indicated. This evolving strategy transforms a disease once considered palliative into one with curative potential in selected patients. In this setting, surgical techniques have also evolved to include artery-first approaches to the SMA and CA, arterial divestment as an alternative to arterial resection, and the triangle operation. Patients with LA-PDAC should be managed in a high-volume centre with experience in treating this type of patient. There is no established role for minimally invasive techniques, including laparoscopic or robotic surgery, with LA-PDAC. Key Messages: Determining the role of surgery for locally advanced pancreatic cancer requires more than just an assessment of the tumour-vasculature relationship. The multidisciplinary selection integrates dynamic imaging, biomarker monitoring, genetic profiling, and physiological evaluation. For some patients, a previous palliative strategy is transformed to a potentially curative one. In this setting, new surgical techniques include an artery-first approach to avoid futile resection, periadventitial dissection instead of arterial resection, and the triangle operation for complete nodal clearance.