Cutting edge blog

Correspondence to: Dr. Davide Serrano (email: davide.serrano@ieo.it)

Division of Cancer Prevention and Genetics

European Insitute of Oncology

It is becoming increasingly common to dedicate days, or even months, to ‘health awareness’. These events should help people to learn about these conditions. From these, we can hope that people might learn about symptoms that help them get a diagnosis, or learn about new treatment options for their conditions. It also provides a focal point where we can come together as a community to recognise those impacted, and find ways to address these serious health conditions. It may even act as a clarion call, moving charities, governments, and individuals, to make efforts to fund and deliver research to further understand and improve outcomes for these conditions.

The BJS Academy, alongside BJS & BJS Open, feel it is an important part of our mission to contribute to these awareness months. So much research is published with enthusiasm, but then resides solely within the pages of a journal (or latterly, as a lonely PDF on a server). It is important to ensure that new information is shared with people who might find it useful. This is particularly important when it comes to conditions which currently have a poor prognosis, or may affect only a small number of people. With this in mind, our team will contribute to the online discussion for disease months by highlighting 2-3 papers from BJS and BJS Open, and sharing them across our social media channels. This will include a short summary and a link to the paper.

This move comes as part of our commitment to sharing key clinical research to support the knowledge of surgeons around the world, and to ensure our patients receive care informed by evidence of the highest possible standard.

Correspondence to: Khalid Hureibi (email: khalid.hureibi@nhs.net)

Kettering general Hospital

Rothwell Rd

Correspondence to: Natasha Houghton (e-mail: tashmh@gmail.com)

Department of Surgery & Cancer

Faculty of Medicine

In recognition, we present seven of the most important liver studies published in BJS and BJS Open over the past year. These articles highlight significant advancements in the understanding and management of liver-related conditions, particularly hepatocellular carcinoma (HCC). Covering topics such as innovative surgical techniques, comparative treatment outcomes, and prognostic markers, this collection showcases the latest research aimed at improving care and outcomes for patients with liver diseases.

Dive into these key contributions to the field and join us in raising awareness of liver health this January.

______

The perioperative care of the patient with obesity continues to attract significant scientific interest. Modern obesity management medications are emerging as valuable tools for addressing obesity and complementing metabolic bariatric surgery, highlighting the need for a tailored, multimodal approach to optimise perioperative outcomes.1,2 A recent consensus panel has provided recommendations for integrating obesity management medications into perioperative care.2 Nonetheless, metabolic bariatric surgery currently remains the most effective long-term treatment for clinical obesity and its complications, highlighting the need for optimal perioperative care.1,2

Since its publication, the 2020 review "Perioperative Care of the Obese Patient" in BJS has garnered significant and enduring interest from the scientific community, remaining a seminal reference in the field five years later.3 The review emphasised the importance of comprehensive preoperative evaluation for patients with obesity, including encouraging preoperative weight loss to prevent or address obesity-related co-morbidities and improve surgical conditions.3 It also highlighted the need for experienced teamwork, appropriate equipment and monitoring, meticulous anaesthetic and analgesic management, and an effective perioperative ventilation strategy3 to enhance postoperative outcomes.3,4 A multidisciplinary approach remains crucial for achieving optimal patient outcomes.3,4

While several studies have been published since, the original review's insights remain largely valid, with some gaps now addressed.3 Regarding anaesthetic choices, conflicting data on propofol versus desflurane3 was clarified by a meta-analysis showing desflurane promotes faster emergence but increases postoperative nausea.5 Multimodal prophylaxis for nausea and vomiting remains essential for patients with obesity undergoing general anaesthesia.3 For neuromuscular block management, sugammadex has proven superior to neostigmine in patients with obesity, providing faster, more predictable reversal of rocuronium-induced neuromuscular block3, while reducing early postoperative pulmonary complications,3,6 as confirmed by a subsequent meta-analysis.6 Multimodal analgesia strategies remain essential for reducing opioid use and related complications in patients with obesity.3 A network meta-analysis demonstrated that intravenous non-opioid analgesics significantly reduce opioid consumption, postoperative nausea, and respiratory complications.7 Another network meta-analysis confirmed the superiority of the transversus abdominis plane block over other regional anaesthesia techniques in reducing pain and nausea, further supporting the findings of the original review.8

Correspondence to: Professor Aneel Bhangu (email: a.a.bhangu@bham.ac.uk)

NIHR Global Surgery Research Unit

University of Birmingham

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has released a consensus position statement addressing the integration of obesity management medications (OMMs) with metabolic bariatric surgery (MBS)1.

Currently, obesity treatment encompasses four primary modalities: lifestyle modification, OMMs, endoscopic bariatric and metabolic therapies (EBMTs), and MBS. The recent introduction of newer-generation OMMs, such as semaglutide and tirzepatide, has sparked a surge in their use and increased awareness of obesity as a treatable chronic disease2,3. While these medications show significant promise, they also have limitations, including non-response rates, potential adverse events, and challenges with long-term adherence.

This position statement is particularly timely, as an increasing number of patients who have tried or discontinued OMMs are now seeking additional interventions to support their weight management or maintenance goals. Furthermore, since not all patients respond optimally to MBS, incorporating adjunctive therapies, such as adding OMMs after surgery, should enhance outcomes.

Sam Tehranchi (email: Ha20813@qmul.ac.uk)

Garrod Building

As the year comes to a close, it’s the perfect time for reflection and catching up on inspiring reads. We’ve handpicked three thought-provoking articles from BJS, BJS Open and BJS Academy. Whether you’re seeking a scientifically enriching review or a compelling surgical career story, these articles make for engaging reads by the fire. From seasoned surgeons to those exploring new horizons, these selections provide up-to-date insights into key surgical topics.

You can also listen to the summaries in our end-of-year podcast available on Spotify.

_______

_______

_______

_______

Correspondence to: Prof. Chengting Zheng, MD (email: just4hao@163.com)

Gastroenterology Disease Center

Chongqing University Three Gorges Hospital

Correspondence to: Elisa J Mäkäräinen (e-mail: elisa.makarainen@pohde.fi)

Department of surgery

Medical Research Centre Oulu

Correspondence to: Sabaretnam Mayilvaganan (email: drretnam@gmail.com)

Additional Professor

Department of Endocrine Surgery

_______

_______

By embracing innovation, addressing research gaps, and fostering collaboration between surgery, endoscopic therapy, and pharmacotherapy, we can revolutionize how we treat this chronic condition, which continues to affect millions of people.

By embracing innovation, addressing research gaps, and fostering collaboration between surgery, endoscopic therapy, and pharmacotherapy, we can revolutionize how we treat this chronic condition, which continues to affect millions of people.

By embracing innovation, addressing research gaps, and fostering collaboration between surgery, endoscopic therapy, and pharmacotherapy, we can revolutionize how we treat this chronic condition, which continues to affect millions of people.

Correspondence to: Andreas Kuehnl (e-mail: a.kuehnl@tum.de)

Department for Vascular and Endovascular Surgery

Klinikum rechts der Isar

Obesity, one of the most profound challenges of modern medicine, casts a shadow over global health, defying decades of simplistic advice to "eat less, move more." For decades, Metabolic and Bariatric Surgery (MBS) has transformed lives by altering the body’s interaction with food through metabolic mechanisms. For patients with severe obesity, surgery has delivered life-altering results, improved metabolic health and reframing obesity as a systemic disease. Yet, MBS is an inherently resource-intensive endeavour. From single-use instruments contributing to hospital waste to individualized preoperative requirements such as psychological evaluation and mandated weight-loss trials, surgery is costly and fundamentally unscalable. It is not a population-wide solution.

Pharmacological innovation offers a transformative opportunity to address this crisis. GLP-1 receptor agonists, with over a decade of real-world use, have redefined treatment possibilities. Medications like Liraglutide and Semaglutide rival the efficacy of surgery, delivering substantial weight loss and metabolic improvement without the invasiveness of an operation. Emerging therapies, such as Tirzepatide and a growing wave of oral agents, promise even greater precision and adaptability. These treatments are inherently scalable, with the potential to reach millions at a fraction of the cost of surgery. In some regions, these therapies are already available for less than $100 per month, opening the door to equitable, population-wide access.

The challenge now lies in navigating a thoughtful transition. MBS has undeniably saved lives, advanced our understanding of obesity, and reshaped public perceptions of its causes. But as pharmacotherapy evolves, the role of surgery will narrow, focusing on rare and complex cases—such as extreme obesity or anatomical complications—where medication alone may not suffice. This shift will demand the reimagination of surgical training, the adaptation of healthcare systems, and a commitment to equity in distributing life-saving medications.

Correspondence to: Haogeng Sun (email: s666888sci@163.com)

37 Guoxuexiang Street, Chengdu

Tel: 028-85423489

To honour Pancreatic Cancer Awareness Month, we’re highlighting some of the most important research published this year in BJS Journals, BJS and BJS Open, on #pancreaticcancer. Advancing research in this field is essential to improving patient outcomes and offering hope. Together, we can make a difference.

There still exists a disparity between the correct anatomical terminology used in medical educational resources, and that which is used in the clinical environment and surgical journals such as the British Journal of Surgery (BJS).1,2 We wish to highlight this as a problem not only for effective communication between healthcare professionals but also the confusion this can cause for students and doctors sitting important examinations.

Anatomical nomenclature forms the basis of medical language. Consistent and unambiguous terminology is essential in an increasingly globalised world, and is crucial to prevent miscommunication between team members in the clinical environment. However a disconnect persists between the terms used by experienced clinicians, and those endorsed as official by the anatomical community, and therefore taught in educational resources.1,2

In a recently published cross-sectional study in BJS1, Dr Marianna Kapestaki examines diversity amongst paediatric consultant surgeons in the UK. It comes as no surprise that the majority of consultants and full professors were men, whilst 73.5% of consultants were white. On the bright side, no gender or racial disparities were found in other academic parameters such as being affiliated with a university or having earned a PhD. Dr Kapestaki presents several other parameters in her study which may or may not be significantly associated with gender, racial or academic inequalities. She goes on to state that the findings in paediatric surgery are consistent with those in neurosurgery and neurology in the UK.

A study like this is important for several reasons. First, it sheds light on the importance of dissecting the surgical workforce for potential inequalities and possible discrimination, including highly subspecialized branches of surgery such as paediatric surgery. Second, it demonstrates that lack of diversity at consultant level is a persisting problem, but one that is definitely remediable once sufficient awareness of the issue is established. Finally, it seems fair to infer from the findings that the solution may lie in the problem itself, namely academia. If there are indeed no disparities in academic achievements such as completing a PhD or becoming affiliated with a university, then with sufficient awareness and deliberation, these same individuals should conscientiously be chosen to higher positions of consultant and full professorship. One can only hope.

We appreciate the thoughtful feedback on our article and welcome this opportunity to address some points raised in the letter and clarify aspects of our study.

While it is accurate that a significant proportion of patients in our study had undergone previous fistula-related surgery, only 31 (28% of patients) had undergone previous attempts specifically aimed at definitive fistula closure, with 22 out of these having had only one prior attempt at closure, as detailed in Table 1. The 92% figure mentioned in the letter refers to the proportion of patients who had undergone any type of previous surgery, including abscess drainage or insertion of seton(s). The majority of these procedures were not definitive repair attempts, so in most cases the intersphincteric plane was not previously entered. Also, we found no compelling literature indicating a direct correlation between previous fistula closure attempts and the healing outcomes of LIFT, nor did not observe this in our analysis. Interestingly, our data did reveal higher healing rates in patients with high trans-sphincteric fistulas, a finding that we acknowledge was somewhat unexpected.