Ioannis Kehagias

Background: Lateral lymph node dissection (LLND) remains controversial owing to differences in oncological principles between East and West, complex pelvic anatomy and the risk of complications. The aim of this systematic review is to determine the number of cases required to achieve surgical competence in LLND and to evaluate postoperative outcomes across different phases of the learning curve. Methods: A systematic literature search was conducted in PubMed and Google Scholar for studies analyzing the LLND learning curve in rectal cancer resection. The three-phase pattern, consisting of learning, competence, and proficiency, was followed for data analysis and presentation. A separate learning curve analysis for open, laparoscopic and robotic LLND was performed. Blood loss, operative time, lymph node yield, urinary complications and postoperative morbidity were assessed across the phases of the learning curve for robotic LLND. Results: Of the 616 articles screened, eight studies met the inclusion criteria. Seven studies reported the learning curve analysis for robotic LLND, and one study for laparoscopic and open approach. Five studies had operative time as a learning outcome, two studies the lymph node yield and one study both lymph node yield and urinary retention. All studies used the cumulative sum (CUSUM) method for learning curve analysis. Regardless of learning outcome, surgical competence for robotic LLND was achieved after 12–53 cases, for laparoscopic LLND after 19 cases, and for the open approach no inflection point was identified. In robotic LLND, blood loss, urinary complications, and morbidity decreased during the proficiency phase. Conclusions: The LLND learning curve is not yet standardized owing to variability in study design, type of LLND, and learning outcomes. Further well-designed and methodologically consistent studies are required to establish learning benchmarks and improve patient outcomes. Registration in PROSPERO database: CRD420251050015.

Post-bariatric hypoglycemia (PBH) is an increasingly recognized complication after metabolic bariatric surgery (MBS). The aim of this study is to investigate potential factors associated with PBH. A cohort of 24 patients with type 2 diabetes mellitus (T2DM) and body mass index (BMI) ≥40 kg/m² who underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP) was retrospectively investigated for PBH at 12 months. PBH was defined as postprandial glucose at 120 min below 60 mg/dL. Questionnaires based on the Edinburgh hypoglycemia scale were filled out by the participants. Glycemic parameters and gastrointestinal (GI) hormones were also investigated. Based on the questionnaires, five patients presented more than four symptoms that were highly indicative of PBH at 12 months. According to glucose values at 120 min, one patient experienced PBH at 6 months and four patients experienced it at 12 months. Postprandial insulin values at 30 min and 6 months seem to be a strong predictor for PBH (p < 0.001). GLP-1 and glucagon values were not significantly associated with PBH. PBH can affect patients with T2DM after MBS, reaching the edge of hypoglycemia. Postprandial insulin levels at 30 min and 6 months might predict the occurrence of PBH at 12 months, but this requires further validation with a larger sample size.