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Background: In patients with localized pancreatic ductal adenocarcinoma (PDAC) undergoing neoadjuvant therapy (NAT) and resection, selection of adjuvant chemotherapy (AC) is typically guided by high-risk features on histopathologic examination. We evaluated the interaction between post-NAT lymph node metrics and AC receipt on survival., Methods: Patients who received NAT followed by pancreatectomy (2010-2020) at seven centers were reviewed. Overall survival (OS) in patients receiving AC or not was stratified by lymph node positivity (LNP) or lymph node ratio (LNR) dichotomized at 0.1. Cox models evaluated the independent association between these nodal metrics, AC receipt, and OS., Results: Of 464 patients undergoing NAT and resection, 264 (57%) received AC. Patients selected for AC were younger (median 63 vs. 67 years; p < 0.001), received shorter duration of NAT (2.8 vs. 3.2 months; p = 0.01), had fewer postoperative complications (Clavien-Dindo grade > 3: 1.2% vs. 11.7%; p < 0.001), and lower rates of pathologic complete response (4% vs. 11%; p = 0.01). The median number of nodes evaluated was similar between cohorts (n = 20 in both; p = 0.9). Post-NAT LNP rates were not different, and median LNR was 0.1, in AC and non-AC cohorts. Both LNP (hazard ratio [HR]: 2.1, p < 0.001) and LNR (0 < LNR ≤ 0.1: HR: 1.98, p = 0.002; LNR > 0.1: HR 2.46, p < 0.001) were independently associated with OS on Cox modeling, although receipt of AC was not associated with improved OS (median 30.6 vs. 29.4 months; p = 0.2). In patients with LNR > 0.1, receipt of AC was associated with significantly longer OS compared to non-AC (24 vs. 20 months, respectively; p = 0.04)., Conclusions: LNR following NAT, not simply nodal positivity, may be useful to refine selection of AC in resected PDAC., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Competing Interests: The authors report no conflicts of interest.

Background: Venous thromboembolism (VTE) is a major cause of morbidity and mortality following distal pancreatectomy (DP). However, the influence of operative technique on VTE risk after DP is unknown., Objective: The purpose of this study was to examine the association between the MIS technique versus the open technique and the development of postoperative VTE after DP., Methods: Patients who underwent DP from 2014 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program pancreas-specific database. Multivariable logistic regression was then used to identify independent associations with the development of postoperative VTE after DP., Results: A total of 3558 patients underwent DP during this time period. Of these cases, 47.8% (n = 1702) were performed via the MIS approach. After adjusting for significant covariates, the MIS approach was independently associated with the development of any VTE (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.06-2.40; p = 0.025), as well as increasing the risk of developing a postdischarge VTE (OR 1.80, 95% CI 1.05-3.08; p = 0.033) when compared with the open approach. There was an association between VTE and the development of numerous postoperative complications, including pneumonia, unplanned intubation, need for prolonged mechanical ventilation, and cardiac arrest., Conclusion: Compared with the open approach, the MIS approach is associated with higher rates of postoperative VTE in patients undergoing DP. The majority of these events are diagnosed after hospital discharge.

Objective: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019)., Summary Background Data: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking., Methods: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology., Results: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety., Conclusion: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Objective: To compare the survival outcomes associated with clinical and pathological response in pancreatic ductal adenocarcinoma (PDAC) patients receiving neoadjuvant chemotherapy (NAC) with FOLFIRINOX (FLX) or gemcitabine/nab-paclitaxel (GNP) followed by curative-intent pancreatectomy., Background: Newer multiagent NAC regimens have resulted in improved clinical and pathological responses in PDAC; however, the effects of these responses on survival outcomes remain unknown., Methods: Clinicopathological and survival data of PDAC patients treated at 7 academic medical centers were analyzed. Primary outcomes were overall survival (OS), local recurrence-free survival (L-RFS), and metastasis-free survival (MFS) associated with biochemical (CA 19-9 decrease ≥50% vs <50%) and pathological response (complete, pCR; partial, pPR or limited, pLR) following NAC., Results: Of 274 included patients, 46.4% were borderline resectable, 25.5% locally advanced, and 83.2% had pancreatic head/neck tumors. Vein resection was performed in 34.7% and 30-day mortality was 2.2%. R0 and pCR rates were 82.5% and 6%, respectively. Median, 3-year, and 5-year OS were 32 months, 46.3%, and 30.3%, respectively. OS, L-RFS, and MFS were superior in patients with marked biochemical response (CA 19-9 decrease ≥50% vs <50%; OS: 42.3 vs 24.3 months, P < 0.001; L-RFS-27.3 vs 14.1 months, P = 0.042; MFS-29.3 vs 13 months, P = 0.047) and pathological response [pCR vs pPR vs pLR: OS- not reached (NR) vs 40.3 vs 26.1 months, P < 0.001; L-RFS-NR vs 24.5 vs 21.4 months, P = 0.044; MFS-NR vs 23.7 vs 20.2 months, P = 0.017]. There was no difference in L-RFS, MFS, or OS between patients who received FLX or GNP., Conclusion: This large, multicenter study shows that improved biochemical, pathological, and clinical responses associated with NAC FLX or GNP result in improved OS, L-RFS, and MFS in PDAC. NAC with FLX or GNP has similar survival outcomes.

Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000-2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.

Background: Controversy persists regarding the management of patients with intraductal papillary mucinous neoplasms (IPMN). International consensus guidelines stratify patients into high-risk, worrisome, and low risk categories., Study Design: The medical records of 7 institutions were reviewed for patients who underwent surgical management of IPMN between 2000 and 2015., Results: There were 324 patients included in the analysis; 60.4% of patients had main-duct/mixed type, and 39.7% had branch-duct IPMN. The median cyst size was 2.65 cm, invasive cancer (IC) or high-grade dysplasia (HGD) was present in 42% (n = 136); 68.9% of patients with high-risk, 40.0% of patients with worrisome, and 24.6% of patients with low risk features exhibited HGD/IC. Multivariate analysis demonstrated that only 1 of 3 high-risk features and 2 of 7 worrisome features predicted the presence of HGD/IC. Positive predictive values for HGD/ IC in patients with obstructive jaundice and lymphadenopathy were 0.83 (95% CI 0.65 to 0.94) and 0.69 (95% CI 0.39 to 0.91), respectively. In the absence of high-risk features, HGD/IC was still present in 57.4% of patients with 2 or more worrisome features. Regression analysis demonstrated that each additional worrisome factor present was additive in predicting HGD/IC in a linear fashion (odds ratio 1.39; 95% CI 1.08 to 1.80; p < 0.01)., Conclusions: These data demonstrate that the current consensus guidelines for surgical resection of IPMN may not adequately stratify and identify patients at risk for having HGD or invasive cancer. Patients with multiple worrisome features, in the absence of high-risk factors, should be considered for resection., (Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The value of spleen preservation with distal pancreatectomy (DP) for benign and low grade malignant tumors remains unclear. The aim of this study was to evaluate the short-term postoperative clinical outcomes in patients undergoing DP with splenectomy (DPS) or spleen preservation (SPDP)., Methods: Online database search was performed (2000 to present); key bibliographies were reviewed. Studies comparing patients undergoing DP with either DPS or SPDP, and assessing postoperative complications were included., Results: Meta-analysis of included data showed SPDP patients had significantly less operative blood loss, shorter duration of hospitalization, lower incidence of fluid collection and abscess, lower incidence of postoperative splenic and portal vein thrombosis, and lower incidence of new onset postoperative diabetes. For the whole group, there was no difference in incidence of postoperative pancreatic fistula (POPF) (RR = 0.95; 95%CI 0.65-1.40, P = 0.80), however, subgroup analysis of studies using ISGPF criteria showed that DPS patients had increased rates of Grade B/C POPF (RR = 1.35; 95%CI 1.08-1.70, P = 0.01)., Conclusions: SPDP for benign and low grade malignant tumors is associated with shorter hospital stay and decreased morbidity compared to DPS. J. Surg. Oncol. 2017;115:137-143. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Introduction: Several groups have defined pancreatic surgery quality metrics that identify centers delivering quality care. Although these metrics are perceived to be associated with good outcomes, their relationship with actual outcomes has not been established., Methods: A national cadre of pancreatic surgeons was surveyed regarding perceived quality metrics, which were evaluated against the Central Pancreas Consortium (CPC) database to determine actual performance and relationships with long-term outcomes., Results: The most important metrics were perceived to be participation in clinical trials, appropriate clinical staging, perioperative mortality, and documentation of receipt of adjuvant therapy. Subsequent analysis of 1399 patients in the CPC dataset demonstrated that a R0 retroperitoneal and neck margin was obtained in 79% (n = 1109) and 91.4% (n = 1278) of cases, respectively. 74% of patients (n = 1041) had >10 lymph nodes harvested, and LN positivity was 65% (n = 903). 76% (n = 960) of eligible patients (surgery first approach) received adjuvant therapy within 60 days of surgery. Multivariate analysis demonstrated margin status, identification of >10 lymph nodes, nodal status, tumor grade and delivery of adjuvant therapy within 60 days to be associated with improved overall survival., Conclusions: These analyses demonstrate that systematic monitoring of surgeons' perceived quality metrics provides critical prognostic information, which is associated with patient survival., (Copyright © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Level 1 data demonstrate that adjuvant chemotherapy (ACT) improves survival after surgical resection of pancreatic ductal adenocarcinoma (PDAC), (adjuvant gemcitabine, CONKO-001 study; adjuvant 5-FU, ESPAC3 study). The role of adjuvant chemoradiation therapy (ACRT) remains controversial. What is less clear is whether adjuvant therapy influences patterns of recurrence. The purpose of this study was to perform the first multicenter study analyzing patterns of recurrence after adjuvant therapy for PDAC., Study Design: Patients undergoing resection for PDAC from 8 medical centers over a 10-year period were analyzed. Demographics, tumor characteristics, operative treatment, type of adjuvant therapy, recurrence pattern, and survival were reviewed. Using Cox-proportional hazards multivariate (MV) regression, the impact of ACT and ACRT on overall survival (OS), local recurrence (LR), and distant recurrence (DR) was investigated., Results: There were 1,130 patients who were divided into those having surgery alone (n = 392), ACT (n = 291), or ACRT (n = 447). Median follow-up was 18 months. Compared with patients undergoing surgery alone, ACT, but not ACRT, demonstrated a significant OS advantage on MV analysis. Patients receiving ACT had significantly fewer recurrences (LR and DR); those receiving ACRT had significantly less LR but not DR. On subset MV analysis, ACT and ACRT resulted in less LR in patients with lymph node (LN) positive and margin negative disease. No improvements in LR, DR, or OS were seen in margin positive patients with either ACT or ACRT., Conclusions: This is the first analysis demonstrating differences in recurrence patterns in PDAC patients based on type of adjuvant therapy. Adjuvant chemotherapy provided an OS advantage likely related to its effect on reducing both LR and DR. Adjuvant chemoradiation therapy appears to decrease LR, but not DR, and therefore has less impact on OS. Future investigations and treatment protocols should consider additional ACT rather than ACRT in the treatment of PDAC., (Copyright © 2016. Published by Elsevier Inc.)

Successful surgical resection offers the only chance for cure in patients with pancreatic cancer. However, pancreatic resection is feasible in less than 20% of the patients. In this review, the current state of surgical management of pancreatic cancer is discussed. The definition of resectability based on cross-sectional imaging and the technical aspects of surgery, including vascular resection and/or reconstruction, management of aberrant vascular anatomy and extent of lymphadenectomy, are appraised. Furthermore, common pancreatic resection-specific postoperative complications and their management are reviewed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The effect of diabetes on survival after resection pancreatic ductal carcinoma (PDAC) is unclear. The present study was undertaken to determine whether pre-operative diabetes has any predictive value for survival., Methods: A retrospective review from seven centres was performed. Metabolic factors, tumour characteristics and outcomes of patients undergoing resection for PDAC were collected. Univariate and multivariable analyses were performed to determine factors associated with disease-free (DFS) and overall survival (OS)., Results: Of the 509 patients in the present study, 31.2% had diabetes. Scoring systems were devised to predict OS and DFS based on a training set (n= 245) and were subsequently tested on an independent set (n= 264). Pre-operative diabetes (P < 0.001), tumour size >2 cm (P= 0.001), metastatic nodal ratio >0.1 (P < 0.001) and R1 margin (P < 0.001) all correlated with DFS and OS on univariate analysis. Scoring systems were devised based on multivariable analysis of the above factors. Diabetes and the metastatic nodal ratio were the most important factors in each system, earning two points for OS and four points for DFS. These scoring systems significantly correlated with both DFS (P < 0.001) and OS (P < 0.001)., Conclusion: Pre-operative diabetes status provides useful information that can help to stratify patients in terms of predicted post-operative OS and DFS., (© 2012 International Hepato-Pancreato-Biliary Association.)

Background: Laparoscopic left pancreatectomy (LLP) is associated with favorable outcomes compared with open left pancreatectomy (OLP). However, it is unclear if the risk factors associated with operative morbidity differ between these two techniques. Guidelines for determining which patients should undergo OLP versus LLP do not exist., Methods: A multi-institutional analysis of OLP and LLP performed in 9 academic medical centers was undertaken. LLP cases were defined in an intent-to-treat manner. Perioperative variables were analyzed to identify factors associated with complications and pancreatic fistulae after OLP and LLP. In addition, complication and fistula rates for patients undergoing OLP and LLP were compared in matched cohorts to determine if one approach resulted in superior outcomes over the other., Results: Six hundred and ninety-three left pancreatectomy cases (439 OLP, 254 LLP) were analyzed. OLP and LLP cases were similar with respect to patient age and American Society of Anesthesiologists score. Body mass index (BMI) was higher in patients undergoing LLP. OLP was more often performed for adenocarcinoma and larger tumors, resulted in longer resected specimen lengths, and more commonly involved concomitant splenectomy. Estimated blood loss was higher and operative times were longer during OLP. On multivariate analysis, variables associated with major complications and clinically significant fistulae differed between OLP and LLP. Patients with body mass index ≤27, without adenocarcinoma, and with pancreatic specimen length ≤8.5 cm had significantly higher rates of significant fistulae after OLP than after LLP; in contrast, no preoperatively evaluable variables were associated with a higher likelihood of significant fistula after LLP versus OLP., Conclusions: Risk factors for complications and pancreatic fistulae after left pancreatectomy differ when open versus laparoscopic techniques are employed. Preoperative characteristics may identify cohorts of patients who will benefit more from LLP, and no patient cohorts had higher postoperative complication rates after LLP than OLP. These observations suggest that LLP may be the operative procedure of choice for most patients with left-sided pancreatic lesions; a more definitive prospective and randomized comparison may be warranted., (@ 2011 Lippincott Williams & Wilkins, Inc.)

Background: As compared with open distal pancreatectomy (ODP), laparoscopic distal pancreatectomy (LDP) affords improved perioperative outcomes. The role of LDP for patients with pancreatic ductal adenocarcinoma (PDAC) is not defined., Study Design: Records from patients undergoing distal pancreatectomy (DP) for PDAC from 2000 to 2008 from 9 academic medical centers were reviewed. Short-term (node harvest and margin status) and long-term (survival) cancer outcomes were assessed. A 3:1 matched analysis was performed for ODP and LDP cases using age, American Society of Anesthesiologists (ASA) class, and tumor size., Results: There were 212 patients who underwent DP for PDAC; 23 (11%) of these were approached laparoscopically. For all 212 patients, 56 (26%) had positive margins. The mean number of nodes (+/- SD) examined was 12.6 +/-8.4 and 114 patients (54%) had at least 1 positive node. Median overall survival was 16 months. In the matched analysis there were no significant differences in positive margin rates, number of nodes examined, number of patients with at least 1 positive node, or overall survival. Logistic regression for all 212 patients demonstrated that advanced age, larger tumors, positive margins, and node positive disease were independently associated with worse survival; however, method of resection (ODP vs. LDP) was not. Hospital stay was 2 days shorter in the matched comparison, which approached significance (LDP, 7.4 days vs. ODP, 9.4 days, p = 0.06)., Conclusions: LDP provides similar short- and long-term oncologic outcomes as compared with OD, with potentially shorter hospital stay. These results suggest that LDP is an acceptable approach for resection of PDAC of the left pancreas in selected patients., (Copyright 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Surgeons are performing laparoscopic left pancreatectomy (LLP) with increasing frequency; however, determinants of perioperative outcome after LLP are not well defined. We evaluated factors contributing to morbidity after LLP., Methods: Records from patients undergoing LLP from 2000 to 2008 from nine academic medical centers were evaluated to assess risk factors for perioperative complications. Extent of pancreatic resection was determined by the length of the gross pancreatic specimen. Complications and pancreatic fistula rates were assessed, and a model was developed to identify those at risk of postoperative adverse events., Results: Among the 219 LLP cases, indications were cystic neoplasms in 122 (56%), solid neoplasms in 83 (38%), and chronic pancreatitis in 14 (6%). Thirty-day morbidity and mortality were 39% and 0, respectively. Major complications occurred in 11%. Pancreatic fistulae were detected in 23%, with clinically important fistulae (International Study Group on Pancreatic Fistula Definition grade B/C) seen in 10%. On multivariate analysis, only greater estimated blood loss (EBL), higher body mass index (BMI), and longer length of resected pancreas were associated with major complications. A complication risk score consisting of 1 point each for BMI >27, pancreatic specimen length >8 cm, or EBL > or =150 mL predicted an increased risk of complications and pancreatic fistulae., Conclusions: The risk of major complications after LLP is 11%, with clinically important pancreatic fistulae occurring in 10%. A complication risk score incorporating BMI, extent of pancreatic resection, and EBL correlates with all end points evaluated. The complication risk score should be used when quality outcome measures are evaluated.

Despite the relatively slow start of laparoscopic pancreatectomy relative to other laparoscopic resections, an increasing number of these procedures are being performed around the world. Operations that were once considered impossible to perform laparoscopically, such as pancreaticoduodenectomy and central pancreatectomy are gaining momentum. Technology continues to improve, as does surgical experience and prowess. There are both enough experience and data (though retrospective) to confirm that LDP with or without spleen preservation appears to be a safe treatment for benign or noninvasive lesions of the pancreas. Based on the fact that LDP can be performed with similar or shorter operative times, blood loss, complication rates, and length of hospital stay than ODP, it can be recommended as the treatment of choice for benign and noninvasive lesions in experienced hands when clinically indicated. It is very difficult to make clear recommendations with regard to laparoscopic resection of malignant pancreatic tumors due to the lack of conclusive data. As long as margins are negative and lymph node clearance is within accepted standards, LDP appears to have no untoward oncologic effects on outcome. Certainly more data, preferably in the manner of a randomized clinical trial, are needed before additional recommendations can be made. Potential benefits of laparoscopic resection for cancer include the ability to inspect the abdomen and abort the procedure with minimal damage if occult metastases are identified. This does not delay the onset of palliative chemotherapy, which would be the primary treatment in that circumstance. In fact, there is evidence to suggest that there is a greater likelihood of receiving systemic therapy if a laparotomy is avoided in patients who have radiologically occult metastases. Patients may also undergo palliative laparoscopic gastric and biliary bypass if indicated. Faster wound healing may also translate into a shorter waiting time before initiating adjuvant chemotherapy and/or radiation therapy. If the patient develops a wound infection, the infection should be more readily manageable with smaller incisions. Although not proven clinically relevant in humans, the reduction in perioperative stress associated with laparoscopic resection may translate to a cancer benefit for some patients. One report compared markers of systemic inflammatory response in 15 subjects undergoing left pancreatectomy. Eight had hand-access laparoscopic procedures and the rest had standard open surgery. The subjects in the laparoscopic group had statistically lower C-reactive protein levels than the open group on postoperative days one (5.5 mg/dL versus 9.7 mg/dL, P = .006) and three (8.5 mg/dL versus 17.7 mg/dL, P = .003), suggesting that the laparoscopic approach to left pancreatectomy is associated with less inflammation. While this report is underpowered, it supports the notion that MIS cancer surgery may induce less of a systemic insult to the body than standard open cancer surgery. More work in this area is necessary before any firm conclusions can be drawn. An important issue to consider is that of training surgeons to perform these complex procedures laparoscopically. Not all pancreatectomies are amenable to the laparoscopic approach, even in the most skilled hands. As such, only a percentage of cases will be performed this way and expectations to educate surgeons adequately to perform advanced laparoscopic procedures can be unrealistic, resulting in more "on-the-job" training. Another aspect that draws some controversy is that of the totally laparoscopic procedure versus the hand-access approach. No laparoscopic instrument provides the tactile feedback possible to obtain with the hand. The HALS approach allows for this, and the opportunity to control bleeding during the procedure. HALS also provides a way to improve confidence during the learning-curve phase of these operations. Finally, it is important to remember that if the procedure is failing to progress laparoscopically, or if cancer surgery principles are likely to be violated, the surgeon (and the patient) must be willing to abort the laparoscopic approach and complete the operation using standard open technique. During the next few years we can expect to see more robust outcome data with laparoscopic pancreatectomy. The expectation is that more data will come to light demonstrating benefits of laparoscopic pancreatic resection as compared with open technique for selected patients. Several groups are considering randomized trials to look at these endpoints. Although more retrospective and prospectively maintained data will certainly be presented, it is less likely that randomized data specifically examining the question oflaparoscopic versus open pancreatectomy for cancer will mature, due to some of the limitations discussed above. Additional areas of discovery are in staple line reinforcement for left pancreatectomy and suturing technology for pancreatico-intestinal anastomosis. Robotic surgery may have a role in pancreatic surgery. Improving optics and visualization with flexible endoscopes with provide novel surgical views potentially improving the safety of laparoscopy. Another area in laparoscopic surgery that is gaining momentum is that of Natural Orifice Transluminal Endoscopic Surgery (NOTES). NOTES represents the "holy grail" of incisionless surgery. Can we enucleate a small tumor off the pancreatic body by passing an endoscope through the gastric (or colonic) wall, and bring the specimen out via the mouth or anus? Can we use this approach for formal left pancreatectomies? Pioneers have already developed a porcine model of left pancreatectomy. This technology must clear several hurdles before it is cancer ready; however, technology is moving at a rapid pace.

Objectives: To compare perioperative outcomes of laparoscopic left-sided pancreatectomy (LLP) with traditional open left-sided pancreatectomy (OLP) in a multicenter experience., Summary and Background Data: LLP is being performed more commonly with limited data comparing results with outcomes from OLP., Methods: Data from 8 centers were combined for all cases performed between 2002-2006. OLP and LLP cohorts were matched by age, American Society of Anesthesiologists, resected pancreas length, tumor size, and diagnosis. Multivariate analysis was performed using binary logistic regression., Results: Six hundred sixty-seven LPs were performed, with 159 (24%) attempted laparoscopically. Indications were solid lesion in 307 (46%), cystic in 295 (44%), and pancreatitis in 65 (10%) cases. Positive margins occurred in 51 (8%) cases, 335 (50%) had complications, and significant leaks occurred in 108 (16%). Conversion to OLP occurred in 20 (13%) of the LLPs. In the matched comparison, 200 OLPs were compared with 142 LLPs. There were no differences in positive margin rates (8% vs. 7%, P = 0.8), operative times (216 vs. 230 minutes, P = 0.3), or leak rates (18% vs. 11%, P = 0.1). LLP patients had lower average blood loss (357 vs. 588 mL, P < 0.01), fewer complications (40% vs. 57%, P < 0.01), and shorter hospital stays (5.9 vs. 9.0 days, P < 0.01). By MVA, LLP was an independent factor for shorter hospital stay (P < 0.01, odds ratio 0.33, 95% confidence interval 0.19-0.56)., Conclusions: In selected patients, LLP is associated with less morbidity and shorter LOS than OLP. Pancreatic fistula rates are similar for OLP and LLP. LLP is appropriate for selected patients with left-sided pancreatic pathology.

This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.