Dimitrios Kehagias

Long-term effects of laparoscopic sleeve gastrectomy (LSG) on lipid metabolism, particularly beyond 10 years, are not well defined. This study evaluated changes in standard lipid parameters and atherogenic indices more than 11 years after stand-alone LSG. This retrospective cohort study included adults who underwent primary stand-alone LSG between 2005 and 2009. Patients with revisional bariatric procedures or major gastrointestinal or appetite-related disorders were excluded. Lipid profiles were assessed preoperatively and at follow-up beyond 11 years. Primary outcomes were long-term changes in triglycerides, total cholesterol, LDL-C, HDL-C, and non-HDL-C. Secondary outcomes included changes in the atherogenic index of plasma, triglyceride/HDL-C ratio, Castelli risk indices I and II, atherogenic coefficient, and use of lipid-lowering medications. Multivariable linear regression was used to identify independent predictors of lipid change. Eighty-six patients (79.1%, female) were analyzed, with a mean follow-up of 13.4 ± 1.3 years. Mean total body weight loss (%TBWL) was 28.8 ± 12.5%. Triglyceride levels decreased from 130.7 ± 64.9 to 91.2 ± 36.8 mg/dL, HDL-C increased from 45.2 ± 9.5 to 62.6 ± 14.7 mg/dL, and non-HDL-C decreased from 151.9 ± 38.0 to 134.0 ± 27.4 mg/dL (all p < 0.001). Total cholesterol remained unchanged, while the reduction in LDL-C was no longer significant after adjustment for multiple comparisons. All five atherogenic indices showed significant improvement (p < 0.001). Greater %TBWL was independently associated with higher HDL-C and lower triglyceride levels at follow-up. More than a decade after stand-alone LSG, improvements in triglycerides, HDL-C, non-HDL-C, and atherogenic indices remain robust. However, these findings should be interpreted cautiously regarding cardiovascular and atherosclerotic risk.

Resectability in pancreatic ductal adenocarcinoma (PDAC) has traditionally been defined according to tumor–vessel relationship on cross-sectional imaging. However, anatomical criteria alone fail to identify occult systemic disease and do not reliably predict early postoperative recurrence or the likelihood of meaningful oncological benefit from surgery. This structured narrative review evaluated contemporary evidence regarding biological resectability and the emerging role of biomarkers in perioperative decision-making. A literature search was conducted using PubMed/MEDLINE, Embase, and Web of Science, focusing on studies published between January 2017 and March 2026, with inclusion of seminal earlier publications where relevant. Priority was given to consensus statements, clinical practice guidelines, meta-analyses, randomized controlled trials, prospective cohort studies, and large multicentre series. Evidence was qualitatively synthesized and biomarkers were classified according to their level of clinical maturity. Emerging data suggest that many anatomically resectable PDACs exhibit biologically aggressive disease associated with occult metastases, early recurrence, and limited benefit from upfront surgery. Among available biomarkers, carbohydrate antigen 19-9 remains the most clinically established and should be interpreted in the context of biliary status, treatment response, and multidisciplinary assessment. Circulating tumor DNA shows promise for molecular staging and recurrence risk stratification, although prospective interventional validation remains limited. Transcriptomic subtypes, positron emission tomography (PET)-derived biomarkers, radiomics, and hybrid multimodal models provide additional biological insights but remain largely investigational. Biological resectability is increasingly recognized as an important complement to anatomical staging, helping to refine patient selection and treatment sequencing. Nevertheless, prospective validation, assay standardization, and biomarker-guided clinical trials are required before widespread implementation in routine multidisciplinary practice.

Introduction: The single-stapling technique (SST) is an alternative to the conventional double-stapling technique (DST), particularly in low rectal surgery. This systematic review and meta-analysis compared anastomotic leak (AL) between SST and DST. Methods: A systematic review of the PubMed/MEDLINE, Google Scholar®, and Scopus databases was conducted in accordance with PRISMA guidelines from inception through December 2025. The primary outcome of interest was AL. A random-effects meta-analysis was used to compare AL, blood loss, operative time, and length of hospital stay between SST and DST. Risk ratios (RRs) were calculated for dichotomous outcomes and mean differences or standardized mean differences were calculated for continuous outcomes. Sensitivity and subgroup analyses were conducted according to surgical approach. Risk of bias was assessed, and the certainty of the evidence for AL was evaluated using the GRADE framework. Results: Of 448 articles screened, 14 were included (2 randomized, 12 observational studies), comprising 1326 patients in the SST group and 1720 in the DST group. SST was associated with a significantly lower risk of AL than DST (RR 0.61; 95% confidence interval 0.42 to 0.90; P = 0.012), with moderate heterogeneity. Sensitivity analysis excluding studies with zero events yielded consistent results. Subgroup analyses showed no difference in AL for open intracorporeal SST compared with DST, a trend toward benefit with minimally invasive intracorporeal SST compared with DST, and a pronounced reduction in AL with transanal SST compared with DST. Conclusions: Although the causes of AL are multifactorial, with respect to the stapling technique, SST was associated with a lower risk of AL than DST, and this effect was primarily driven by transanal SST. However, the certainty of evidence is low, and ongoing prospective studies will better define the role of SST.

Background: Metabolic bariatric surgery (MBS) has been associated with improved clinical outcomes of psoriasis, yet evidence-based guidelines remain unclear. This systematic review aims to analyze current evidence on psoriasis outcomes following MBS and identify factors influencing clinical response. Methods: A systematic literature search of PubMed®, Scopus, and Google Scholar® was conducted according to PRISMA guidelines. Data extracted included study design, patient demographics, type of MBS, weight loss, and psoriasis outcomes assessed by Psoriasis Area Severity Index (PASI), percentage of affected body surface area (%ABSA), nail involvement, Dermatology Life Quality Index (DLQI), and treatment requirements. Subgroup analysis compared gastric bypass with non-bypass procedures. Due to heterogeneity, a qualitative synthesis was performed. Results: Six studies involving 447 patients were included. Demographic data were available for 159 patients (mean age 46.9 years, mean BMI 43.8 kg/m²). Pooled BMI reduction was 11.0 ± 3.3 kg/m². Baseline therapies included systemic in 53%, topical in 44%, and phototherapy in 5%. After surgery, systemic therapy decreased to 34%, topical to 39%, and 29% required no treatment. DLQI decreased from 14.9 to 5.0, %ABSA from 5.7 to 1.7, PASI from 3.6 to 1.2, and nail involvement from 43.8% to 21.9% (p < 0.05). Overall, 69.5% of individuals demonstrated improvement or remission of psoriasis, primarily defined by reduced or discontinued treatment. Improvement or remission was noted in 80% of gastric bypass and 10% after non-bypass surgery, with higher PASI reduction after bypass (ΔPASI 2.32 vs 1.67). Factors related to improved clinical response included greater excess weight loss, older age, Roux-en-Y gastric bypass and absence of family history of psoriasis. Conclusions: MBS may improve psoriasis severity, quality of life, and treatment requirements, but current evidence is uncertain. Weight loss magnitude, type of MBS and patient characteristics might affect clinical response of psoriasis. Further prospective studies are required to establish personalized management among individuals with psoriasis and obesity. Trial registration: Registration of systematic review: PROSPERO database (UIN: CRD420251108229)

Background: Perforation and anastomotic leak (AL) of the esophagus remain a dreaded complication for surgeons, endoscopists and patients. The VacStent is a novel endoscopic device, combining the benefits of a self-expandable metallic stent (SEMS) and endoscopic vacuum therapy (EVT). This systematic review aims to investigate the efficacy and clinical outcomes associated with the use of the VacStent. Methods: A systematic literature review was conducted in PubMed and Google Scholar electronic databases using keywords and Medical Subject Headings terms. Peer-reviewed studies in English language that reported the use of VacStent for transmural defects of any cause of the esophagus and gastroesophageal junction (GEJ) were included. Data regarding technical details of the VacStent, outcomes, and complications were extracted and presented in a narrative synthesis. Clinical success was defined as closure of the defect without requiring further intervention. Results: Of the 153 articles identified after searching, nine studies were deemed eligible and included in the final analysis. The methodological quality of the included studies was generally moderate. Sixty-five patients underwent VacStent treatment for the following indications: AL (70%), Boerhaave syndrome (10%), iatrogenic perforation (10%), and other causes (10%). The mean interval between VacStent changes was 5.3 (2–8) days. Prior endoscopic interventions, including SEMS, clips, and EVT, had been performed in 25 patients (38%). The mean duration of VacStent therapy was 8.8 ± 8.3 days. On average, each patient received between one and three VacStents. Technical success was achieved in all 65 cases (100%), while clinical success was observed in 50 patients (77%). Approximately 70% of patients were able to tolerate a liquid diet during treatment, and no major complications were reported. Conclusions: The VacStent appears as a promising tool, integrating the benefits of both EVT and SEMS, while allowing oral intake. The included studies present preliminary data, warranting cautious interpretation. Further evidence is required to delineate the clinical utility and appropriate indications for VacStent therapy. Trial Registration: PROSPERO database (UIN: CRD420251012718).

Identifying the critical view of safety (CVS) and other safe anatomic landmarks during laparoscopic cholecystectomy (LC) is the cornerstone for avoiding bile duct injuries (BDI). Artificial intelligence (AI), which has infiltrated in the operating room, appears as a promising tool, enabling surgeons to safely dissect during LC. The aim of this study is to investigate the AI models and their performance for identifying these critical structures. A systematic literature review of the PubMed and Google Scholar databases was conducted using medical subject headings (MeSH). Studies presenting the application of AI models for identifying CVS and anatomic landmarks were included and analyzed in terms of performance and reliability. Clinical feasibility trials with preliminary data were separately analyzed. Seventeen studies were found eligible and analyzed for various parameters. Generating AI models for identifying CVS and anatomic landmarks during LC is feasible, while their performance in terms of accuracy, precision and recall has remarkably improved. Regarding their reliability, intersection over union (IoU) and F1/Dice scores have been improved, as well. AI models can be successfully deployed in the operating room, and could assist surgeons in decision-making. Implementation of AI during LC for identifying CVS and important anatomic landmarks appears as a feasible and promising option. Preliminary data are encouraging in terms of performance but still major obstacles and barriers need to be overcome. Whether this will lead to reduced BDIs and enhanced patient safety, requires more well-designed studies. PROSPERO database registration: (UIN: CRD42024557432).