Rationale:
There are no established guidelines or high-quality evidence supporting the widespread use of a fat-free diet in patients with cholecystitis or biliary colic, either as part of conservative treatment or postoperatively. This is the first clinical trial to assess the role of a more flexible diet, World Health Organization (WHO) diet, characterized by total fat <30% of daily energy intake and limited saturated fats (<10%), as an alternative to the traditionally prescribed fat-free diet, which contains <5% of total daily energy from fat, in symptomatic gallstone disease.

Methods:
Patients presenting with biliary colic or acute cholecystitis(RADIGAL-1), or undergoing cholecystectomy for gallstones(RADIGAL-2), are randomized to receive recommendations for either a fat-free diet or a WHO-diet. A follow-up at 3 months evaluates adherence, adverse events, and quality of life using the validated Gastrointestinal Quality of Life Index (GIQLI). Based on sample size calculations, recruitment targets are 136 patients for RADIGAL-1 and 106 for RADIGAL-2.

Results:
To date, 71.3% of the planned recruitment target for RADIGAL-1 and 92.5% of RADIGAL-2 participants have completed the 3-month follow-up. In RADIGAL-1, 88.7% achieved full compliance, 7.2% adhered for more than 50% of the time, and 2.1% adhered for less than 50% of the time. In RADIGAL-2, the compliance rates were similar: 89.8%, 7.1%, and 3.1%, respectively. The main reason for less than full adherence was that participants did not experience any symptoms (83%). Rates of adverse events were similar between diet groups (RADIGAL-1: 20.8% vs.22.4%, p=0.8; RADIGAL-2: 12.5% vs.18.4%, p=0.4), as were hospital readmissions (RADIGAL-1: 20.4% vs.12.5%,p=0.4; RADIGAL-2: 4.1% vs.4.2%,p=0.9). A decrease in QoL at 3 months was more frequent in the fat-free group (14.9% vs.4.2%,p=0.4 in RADIGAL-1; 6.1% vs.12.5%,p=0.4 in RADIGAL-2). At 3 months, GIQLI scores were similar between diet arms in both trials (RADIGAL-1: 136.4 ± 6.8 vs.136.3 ± 6.7; mean difference−0.1, 95% CI−2.8 to 2.6; p=0.9; RADIGAL-2: 134.8 ±10.7 vs.135.8 ±11.9; mean difference 1.0, 95% CI−3.6 to 5.6; p=0.7).

Conclusion:
Preliminary results suggest that the WHO diet is not inferior to the empirically prescribed fat-free diet in the management of symptomatic gallstone disease, regarding biliary adverse events and quality of life.

Background

Major intraoperative bleeding remains an important cause of surgical morbidity and mortality. Blood transfusion, though often life-saving, is a limited resource and carries risks including transfusion reactions, infection, and increased length of stay. Tranexamic acid (TXA) is a low-cost antifibrinolytic that has been shown to reduce bleeding and transfusion requirements in surgery. National guidance, including the Joint Royal Colleges Implementation Group and NICE QS138, recommends administration of 1 g TXA before incision and again after closure for all adult surgical patients at risk of moderate blood loss. Despite these recommendations, TXA use in general surgery is often inconsistent.

Methods

We conducted a retrospective audit of consecutive moderate-risk colorectal operations performed at [SMH and WGH] between 1 September and 31 November 2024. Data were obtained from electronic records. Outcomes included whether TXA was administered correctly (both timing and dose), estimated intraoperative blood loss, and postoperative requirement for blood transfusion or iron replacement. A total of 96 procedures were identified, of which 2 were excluded due to missing records.

Results

Correct TXA administration was documented in only 4/96 (4%) patients, while 13 patients received an incomplete or incorrect regimen. Intraoperative blood loss was generally minimal, although documentation was absent in 31% of cases. One quarter (25%) of patients required postoperative transfusion or iron therapy. Notably, among the 4 patients who received the correct TXA regimen, only 1 required a transfusion. In contrast, patients needing transfusion or iron were predominantly those who had not received TXA or had received it incorrectly.

Conclusion

This audit demonstrates marked underuse of TXA in general surgery, despite clear evidence and national recommendations. A checklist prompt at time of WHO surgical safety sign-in, combined with targeted education of anaesthetic and surgical teams, represents a low-cost and high-yield intervention. Optimising TXA use has the potential to reduce unnecessary transfusions, conserve blood resources, and improve perioperative outcomes.

Axillary involvement in hidradenitis suppurativa (HS) presents unique surgical challenges due to the region’s high mobility, which can hinder wound healing, as well as high recurrence rates and limited consensus on optimal closure methods. Although surgical intervention for severe HS is increasing, comparative data on closure strategies, such as secondary intention, grafts, and flaps, remain sparse, complicating standardization of care. The objective of this review was to evaluate and compare surgical outcomes of axillary HS across closure techniques, highlighting data gaps and informing treatment algorithms. A systematic literature review was conducted using PubMed with the following search string: (((axilla) AND (hidradenitis)) AND (surgical outcomes)) AND (closure). Articles published between 2010 and 2025 were screened. Included studies evaluated axillary HS treated with defined surgical closure techniques and reported on healing time, recurrence, complications, or functional outcomes. Exclusion criteria were non-English language studies, a non-axillary focus, or lack of outcome-specific data. Ten studies were included; several focused exclusively on axillary HS, though total axillary case volume was inconsistently reported. Healing by secondary intention was common, associated with fewer complications but prolonged healing. Flap-based techniques, such as thoracodorsal artery perforator (TDAP), posterior arm, parascapular, and V-Y advancement flaps, offered faster recovery and improved mobility, though donor site issues like dehiscence and seroma varied. Split-thickness skin grafts showed intermediate healing times and recurrence. One prospective study comparing TDAP flaps to secondary intention reported superior quality of life and function. Few studies used validated patient-reported outcomes or standardized recurrence definitions. This review highlights the lack of standardized outcome metrics for axillary HS and the need for validated tools to assess healing, recurrence, and patient satisfaction. The existing literature is limited by inconsistent follow-up, nonuniform recurrence definitions, and scarce utilization of patient-reported outcomes. Future research should prioritize prospective, multicenter trials using real-world data to develop evidence-based, anatomically-tailored surgical strategies.

Background:
Gallbladder volvulus is a rare but potentially life-threatening condition caused by torsion of the gallbladder on its mesentery, leading to compromised vascular supply and biliary obstruction. Its clinical and radiological features are often non-specific, making pre-operative diagnosis challenging. Prompt surgical intervention is essential to prevent necrosis, perforation, and sepsis. Awareness of patient risk factors—such as advanced age, female sex, spinal deformities, and loss of visceral fat—is important for early recognition.

Case Presentation:
A 77-year-old female presented with sudden-onset severe epigastric pain radiating to the back, accompanied by nausea, vomiting, and anorexia. The pain was persistent and unresponsive to analgesia. Her history included gastro-oesophageal reflux disease, chronic kidney disease stage 3, hiatus hernia, and spinal stenosis, though she remained functionally independent.

Laboratory investigations were largely unremarkable, with only a mildly elevated alkaline phosphatase. Differential diagnoses included acute cholecystitis and gastric volvulus. Computed tomography revealed a distended gallbladder in an abnormal position between the diaphragm and liver segment VIII. Magnetic resonance cholangiopancreatography further demonstrated displacement of the gallbladder with a possible twisted cystic pedicle, highlighting the importance of careful imaging review in atypical presentations.

She underwent emergency laparoscopic cholecystectomy. Intra-operatively, the gallbladder was located above the liver dome with torsion of the cystic duct and artery, confirming volvulus. She made an uneventful recovery and was discharged on postoperative day four with outpatient follow-up.

Conclusion:
This case underscores the diagnostic challenges of gallbladder volvulus and the importance of maintaining a high index of suspicion in elderly patients with acute abdomen. Early recognition, attention to imaging clues, and prompt surgical intervention are critical to achieving favourable outcomes.

Introduction:
Iron deficiency anaemia (IDA) is frequently attributed to nutritional deficiency, menstrual loss, or chronic gastrointestinal bleeding. When upper and lower endoscopies are unremarkable, small bowel pathology must be considered. Venous haemangiomas of the small intestine are exceptionally rare, comprising less than 0.05% of all gastrointestinal neoplasms. These lesions are usually small, asymptomatic, and often missed on standard imaging. We report a unique case of a large 13 cm jejunal venous haemangioma causing longstanding IDA.

Case Presentation:
A 36-year-old male lorry driver presented with worsening fatigue, exertional dyspnoea, and somnolence. He had a 19-year history of unexplained IDA, with persistently low haemoglobin (Hb 75 g/L) and ferritin (2 µg/L) despite regular iron supplementation. Initial workup, including OGD and colonoscopy, was unrevealing. Ongoing symptoms and positive fecalimmunochemical testing (FIT 39.8) prompted further evaluation. Capsule endoscopy and balloon-assisted enteroscopy identified a suspicious, bleeding lesion in the jejunum. PET-CT and MRI suggested a hypervascular mass concerning for malignancy. Laparoscopic small bowel resection was performed. Histopathology confirmed a 13 cm benign venous haemangioma without evidence of dysplasia or malignancy.

Discussion:
This case highlights the diagnostic challenge of obscure small bowel bleeding. Large venous haemangiomas may mimic malignancies or angiodysplasias on imaging, and their location often delays diagnosis. In this patient, multiple negative investigations over nearly two decades underscore the importance of considering small bowel sources early in chronic IDA, particularly in younger males without overt bleeding. Capsule endoscopy and enteroscopy played pivotal roles in diagnosis and localisation, facilitating definitive surgical management.

Conclusion:
Persistent IDA with negative bidirectional endoscopy warrants early evaluation of the small bowel. Although rare, large venous hemangiomas should be included in the differential diagnosis for obscure gastrointestinal bleeding. Prompt identification and surgical resection can be curative, significantly improving the patient's quality of life.

Background and Objective:
Multiple prospective and retrospective cohort studies from Western countries have reported conflicting results regarding the efficacy of direct-acting antivirals (DAAs) in achieving sustained virologic response (SVR) among patients with hepatitis C virus (HCV) infection. However, there is limited evidence from South Asia, and almost no data evaluating the effectiveness of triple therapy with ribavirin, sofosbuvir, and daclatasvir in cirrhotic HCV-infected patients from Pakistan. Understanding the real-world effectiveness of this regimen is crucial for improving patient outcomes in resource-limited settings. This study aimed to assess treatment outcomes and identify factors associated with SVR in this population.

Methods:
We conducted a retrospective cohort study of 359 HCV-infected patients treated with triple therapy at two tertiary care hospitals in Pakistan between February 2018 and June 2019. Of these, 187 (53%) were cirrhotic and 172 (47%) non-cirrhotic. Follow-up was incomplete for 158 (44.1%) patients due to death (n = 24, 6.68%), non-response to contact (n = 43, 9.63%), or withdrawal/refusal (n = 91, 25.34%). The final analysis included 201 (55.9%) patients, of whom 87 (43.2%) were cirrhotic, classified using the Liver Stiffness Index. Patients were stratified into SVR and non-SVR groups for comparison.

Results:
Among 201 patients completing follow-up, mean age was 50.6 ± 10.65 years. SVR was achieved in 81 cirrhotic patients (94.2%), while 5 (5.8%) failed therapy. SVR achievement was significantly associated with lower platelet count, elevated total bilirubin, and reduced albumin (p < 0.05). Other demographic and disease-related factors were not statistically significant.

Conclusion:
Triple therapy with ribavirin, sofosbuvir, and daclatasvir demonstrated a high SVR rate (>94%) in Pakistani cirrhotic patients, highlighting its effectiveness in this population. These findings support its continued use as a valuable therapeutic option and provide real-world evidence to guide clinical decision-making and policy development in similar resource-limited settings.

Background: Malignant obstructive jaundice is a frequent complication of pancreaticoduodenal and hilar hepatic tumors. It significantly impairs quality of life, reduces survival, and often prevents continuation of oncological treatment. The standard method of treatment is endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting; however, some patients require alternative biliary decompression.

Aim: The study aimed to compare the effectiveness, complications, and overall survival of endoscopic ultrasound-guided (EUS) transluminal procedures with those of percutaneous transhepatic biliary drainage (PTBD).

Materials: A retrospective analysis was performed on 104 patients with malignant biliary obstruction in whom ERCP with biliary stenting had failed. Thirty-nine patients underwent EUS-guided procedures, and sixty-five patients underwent PTBD. Clinical success was defined as a reduction in serum bilirubin concentration. Demographic data, complications (Clavien–Dindo classification), length of hospitalization, and survival were analyzed using logistic and linear regression.

Results: Clinical success was achieved in 91 out of 104 patients (87.5%), and the efficacy of both techniques was comparable (EUS: 91.9%, PTBD: 87.7%, p = 0.742). Complications occurred more frequently in the EUS group (41% vs. 12.3%, p = 0.001), including death in three individuals. PTBD-related complications were limited to Clavien-Dindo II. The mean hospital stay did not differ significantly (5.4 vs. 4.9 days, p = 0.258). Median survival was 66 days in the EUS group and 93.7 days in the PTBD group, with a higher 30-day mortality rate in the PTBD group (33.9% in the PTBD group, 10.3% in the EUS-guided group).

Conclusion: Both methods, PTBD and EUS-guided drainage, are equally effective alternatives after failed ERCP. EUS-guided drainage offers a slightly higher success rate but carries a greater risk of severe complications. PTBD was associated with higher short-term mortality but had a better safety profile.

Abstract

Background: The aggressiveness of liver cancer, especially hepatocellular carcinoma (HCC), and the lack of early diagnosis make liver cancer a significant global health issue. This study aims to analyse transcriptomic data from The Cancer Genome Atlas (TCGA-LIHC) project to identify patterns of differential gene expression between tumor and normal liver tissues. Materials and Methods: The analysis focused on the 20 most variable genes using statistical visualization methods such as boxplots, density plots, and heatmaps. Principal component analysis (PCA) and Random Forest classification models were employed to detect expression differences and assess predictive capabilities. Results: The findings revealed distinct expression patterns, with some genes (e.g., GLUL, FTL, APOA2) upregulated in tumor samples, while others (e.g., ALB, APOA1, ALDOB, HP, FGA) were downregulated, reflecting cancer-specific transcriptional activity. Strong gene–gene correlations suggested the presence of co-regulated modules potentially involved in oncogenic pathways. PCA demonstrated a clear separation between tumor and normal tissues, and the Random Forest model achieved high classification accuracy with a low error rate, particularly in identifying tumor tissues. Functional enrichment analysis further revealed significant involvement of coagulation, complement, and lipid metabolism pathways, providing biological context for the expression differences. External validation using an independent GEO cohort (GSE14520) confirmed the robustness of the 20-gene panel, with elastic-net achieving an AUC of 0.97 and Random Forest reaching an AUC of 0.9998, supporting reproducibility across platforms. Conclusion: These results support the potential of expression-based biomarkers in distinguishing liver cancer states and lay the groundwork for developing diagnostic or therapeutic strategies. Although further validation in independent cohorts and experimental settings is necessary, this study highlights the value of integrative bioinformatics in uncovering molecular signatures critical to advancing liver cancer research and clinical management.

Background

Medication-related osteonecrosis of the jaw (MRONJ) is a serious adverse effect of antiresorptive drugs (such as bisphosphonates, denosumab) or antiangiogenic drugs. These therapies are primarily used to prevent pathological fractures of long bones associated with cancer or osteoporosis. MRONJ is characterized by a non-healing jawbone exposure, accompanied by persistent symptoms of inflammation. The necrosis complicates cancer therapy and significantly impacts the patients' quality of life.

The aim

Analysis and characteristics of the population of patients who developed MRONJ and were treated at the Department and Clinic over a 4-year period.

Material and method

This paper presents a retrospective clinical observation of 60 patients treated with MRONJ at the Department and Clinic of Cranio-Maxillofacial Surgery of the Silesian Medical University in Katowice between 2020 and 2024. After applying the study inclusion criteria, 41 patients were ultimately enrolled. The study considered the following patient parameters: gender, age, underlying disease, causative factors, type and route of antiresorptive drug administration. Particular attention was paid to the clinical symptoms in the oral cavity, location, stage and size of the necrotic lesions.

Results

The mean age of the patients in the study’s population was 68.3 (age_min=44, age_max=90), 73.2% (n=30) were taking antiresorptive medications due to cancer, and 26.8% (n=11) were taking antiresorptive medications due to osteoporosis. Gender was another key factor, as 73.2% (n=30) of patients were women. In the study group, the majority (85.4%, n=35) of patients were diagnosed with AAOMS stages II and III of MRONJ. Necrotic lesions were primarily located in the mandible (70.7%, n=29). Tooth extraction was identified as a causative factor in 61.0% of cases (n=25). Moreover, in 31.7% (n=13) of patients, denture was suspected as a factor of trauma to the dental arch, which was later diagnosed with necrosis.

Conclusions

Poor oral health, surgical procedures, and trauma from ill-fitting dentures can often be triggers for drug-induced osteonecrosis of the jaw.

Prehabilitation is a cost-effective, safe, and side-effect-free intervention that can positively impact respiratory function, which is particularly important before thoracic surgery. However, it is not widely used. Its goal is to improve the patient's overall health, minimize the risk of complications, and ensure the fastest possible recovery. This is particularly important for high-risk surgical patients, who are typically elderly and suffer from multiple comorbidities. Implementing prehabilitation programs, rationally speaking, aims to establish contact with patients as soon as possible after diagnosis.

The pilot study involved 30 patients of both sexes with lung cancer who participated in a prehabilitation program prior to surgery at the Thoracic Surgery Department of the University Hospital in Rzeszów. Based on established standards for each patient, two volume measurements were performed before and after the physiotherapy procedure. Inspiratory capacity measurements were performed using the Voldyne 5000 device, designed to measure and support the effectiveness of breathing exercises, which is a way to improve patients' self-efficacy.
The measurements showed that inspiratory capacity, calculated according to specific standards, averaged 1686.67 ml ± 644.06 ml before the start of prehabilitation, and after individually tailored physiotherapy, it increased to 2030 ml ± 631.86 ml in the study participants. The mean difference of 343.33 ml ± 264.49 ml was statistically significant.
Patients' adherence to recommendations and performance of prehabilitation exercises during the preparatory period was effective. Prehabilitation was associated with improved performance before surgery, and future studies may demonstrate that this will lead to a shorter hospital stay and fewer complications. Respiratory therapy as part of preoperative preparation is an effective rehabilitation method, as confirmed by volumetric studies. Patients who completed the prehabilitation program experienced improved respiratory function. The program's success may be attributed to a number of principles and expertise acquired from sources recommended by the National Institute for Health and Care Excellence in Pulmonary Rehabilitation