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Background: In this study, we report the use of a complex surgical intervention termed modular one-stage emergent pancreaticoduodenectomy (MOEPD) for the treatment of acute Grade IV or V pancreaticoduodenal injuries in haemodynamically stable patients. We summarize the experiences of surgeons performing MOEPD in 12 patients from 3 centres., Methods: From 2015 to 2021, the clinical data of patients with blunt abdominal trauma who underwent MOEPD were extracted from three Chinese centres. The patients' perioperative variables were assessed., Results: All twelve MOEPD cases were analysed. All patients had Grade IV or V pancreatoduodenal injuries and received intensive antishock treatment for haemodynamic stabilization. The mean age of the patients was approximately 45.2 years (22-74 years). Ten patients (83.3%) were male. In contrast to the ten patients who underwent pancreaticoduodenectomy (PD), two patients underwent laparoscopic pancreaticoduodenectomy (LPD). Two patients presented with a combination of severe abdominal injuries. None the patients died in the perioperative period. Five patients (41.7%) experienced postoperative complications. A postoperative pancreatic fistula (POPF) was detected in 16.7% of patients, both of whom recovered within 3-4 weeks with conservative drainage. All patients were released from the institutions after an average of 31.8 days (21-53 days). There was no statistically significant difference in the incidence of complications between the 20 reviewed studies and this group (60.7% vs. 41.7%, P = 0.33), but the mortality rate was lower in this group (26.6% vs. 0%, P = 0.04)., Conclusions: The experiences at these 3 centres suggest that MOEPD may be a lifesaving procedure for haemodynamically stable patients with acute Grade IV or V pancreatoduodenal injuries, despite the small sample size of this study., Clinical Trial Number: Not applicable., Competing Interests: Declarations. Human ethics and consent to participate: The experimental protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of The Affiliated Yixing Hospital of Jiangsu University(Yixing People’s Hospital). The ethical approval number was IRB-2024-RESEARCH-070-01. This was a retrospective study, so informed consent was not required. All methods were carried out in accordance with relevant guidelines and regulations. Consent for publication: Consent for publication was obtained from each patient. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Minimally invasive pancreaticoduodenectomy (MIPD) has seen increased adoption due to advancements in surgical techniques and technology. However, the impact of hepatic artery variations (HAV) and clinically relevant HAV (CR-HAV) on MIPD outcomes remains under-investigated. This study aims to explore the differences in surgical and oncological outcomes of MIPD with or without HAV and CR-HAV., Methods: We enrolled 267 consecutive patients who underwent MIPD at Peking Union Medical College Hospital between January and December 2023. HAV was identified preoperatively through enhanced abdominal CT and three-dimensional reconstruction, and classified according to the Michels and Hiatt systems. Clinically relevant hepatic artery variations (CR-HAV) were defined based on their potential impact on the surgical approach. We collected and analyzed perioperative data and oncological outcomes between patients with and without HAV and CR-HAV. Propensity score matching (PSM) was used to minimize baseline confounding. Survival analysis was performed using the Kaplan-Meier method with log-rank tests., Results: HAV was identified in 26.1% of patients, and CR-HAV in 18.9%. The median operation time was significantly longer in HAV (+) group compared to HAV (-) group (6.72 vs. 5.80 h, p = 0.013). No significant differences were found between HAV/CR-HAV (+) and (-) groups regarding intraoperative blood loss, conversion to laparotomy, postoperative complications, surgical mortality, length of stay, re-operation, and re-admission. Kaplan-Meier survival analysis showed no significant differences in overall survival or progression-free survival between HAV/CR-HAV (+) and (-) groups in the malignant cohort., Conclusion: HAV and CR-HAV do not significantly impact overall or progression-free survival in patients undergoing MIPD. While HAV is associated with longer operation times, other perioperative and oncological outcomes remain comparable between HAV/CR-HAV (+) and (-) groups., Competing Interests: Declarations. Ethical approval: This study was approved by the Ethics Committee of Peking Union Medical College Hospital and written informed consent was obtained from all patients. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). We have obtained consent from all authors and they have agreed to publish the results of this study. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Objective: Ampullary neoplastic lesions can be resected by endoscopic papillectomy (EP) or transduodenal surgical ampullectomy (TSA) while pancreaticoduodenectomy is reserved for more advanced lesions. We present the largest retrospective comparative study analysing EP and TSA., Design: Of all patients in the database, lesions with prior interventions, benign histology advanced malignancy (T2 and more), patients with hereditary syndromes and those undergoing pancreatoduodenectomy were excluded. All remaining cases as well as a subgroup of them, after propensity-score matching (nearest-neighbour-method) based on age, gender, anthropometrics, comorbidities, size and histological subtype, were analysed. The median follow-up was 21 months (IQR 10-47) after the primary intervention. Primary outcomes were rates of complete resection (R0) and complications. Groups were compared by Fisher's exact or χ 2 test, Mann-Whitney-U-test and log-rank test for survival., Results: Of 1673 patients in the database, 1422 underwent EP and 251 TSA. Of them, 23.2% were excluded for missing or inconclusive data and 19.8% of patients for prior interventions or hereditary syndromes. Final histology showed in 24.2% of EP and 14.8% of TSA patients a histology other than adenoma or adenocarcinoma while advanced cancers were recorded in 10.9% of EP and 36.6% of TSA patients. Finally, 569 EP and 63 TSA were included in the overall analysis, with a higher rate of more advanced cases and higher R0 resection rates in the TSA groups (90.5% vs 73.1%; p<0.01), with additional ablation in the EP group in 14.4%. Severe adverse event rates were 3.2% (TSA) vs 1.9% (EP). Recurrence after histological R0 resection was 16% (EP) vs 3.2% (TSA; p=0.01), and additional therapy for R1 resection was applied in 67% of the 159 cases. Propensity-score-based matching identified 62 pairs of EP/TSA patients with comparable baseline patient and lesion characteristics. The initial R0-rate was 72.6% (EP) compared with 90.3% (TSA, p=0.02) with recurrences found in 8% (EP) vs 3.2% (TSA; p=0.07); reinterventions were more frequent in the EP group. Overall survival was comparable., Conclusions: The rate of patients with poor indications due to non-neoplastic disease or advanced cancer is still high for both EP and TSA; multiple retreatments were necessary for EP. Although EP can be considered an appropriate primary therapy for certain ampullary adenomas, case selection for both therapies (especially with regard to the best step-up approach) should be studied further., Competing Interests: Competing interests: MH: Honoraria from FUJIFILM for lectures and expert panel. Honoraria from Falk Foundation for lectures. MBruno: Boston Scientific: consultant (money to institution), support for industry and investigator-initiated studies. Cook Medical: consultant (money to institution), support for industry and investigator-initiated studies. Pentax Medical: consultant (money to institution), support for investigator-initiated studies. Mylan: lecturer, support for investigator-initiated studies. ChiRoStim: support for investigator-initiated studies.MDC received a research grant Boston from Haemonetics,INC and he is co-PI of a Boston Scientific sponsored study, (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: Pancreaticoduodenectomy (PD) is a complex operation associated with high morbidity, especially in the setting of hepatic fibrosis/cirrhosis and portal hypertension. Portal hypertension can be a near-certain contraindication for PD, potentially precluding patients with resectable malignancy from a curative operation. Transjugular intrahepatic portosystemic shunt (TIPS) is an artificial path between the portal vein and suprahepatic veins for decreasing the portal pressure, defined as a hepatic venous pressure gradient > 5 mmHg. TIPS can be used as a bridge to facilitate the safe performance of PD., Methods: This is a single-institution retrospective analysis of patients treated with TIPS prior to PD from July 2011 to July 2022. The patient's preoperative management, perioperative course, and postoperative complications were analyzed and reported., Results: Out of 1140 patients in a pancreatic resection database, four underwent preoperative TIPS before PD. The cohort included two males and two females, with a mean age of 66 years and body mass index of 30.2. All patients had portal hypertension, with a reduction in the mean gradient following TIPS, 13 mmHg to 2.5 mmHg. Three patients had cirrhosis, and one had portal thrombosis. The median estimated blood loss and operative time were 275 mL and 267 min, respectively. Postoperatively, one patient experienced a grade IIIa complication and three developed hepatic encephalopathy at a median of 98 days. All patients received chemo-radiation (two neoadjuvant, three adjuvant) and developed recurrent metastatic disease at a median of 13.5 months. Median overall survival was 21.8 months., Conclusion: TIPS in patients with portal hypertension should be considered as a bridge to a safe PD for patients with peri-ampullary adenocarcinoma., Competing Interests: Declarations. Conflict of Interest: The authors declare no competing interests., (© 2025. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In preoperative staging for patients with a ductal adenocarcinoma of the pancreatic head (PDAC), resectability is anatomically characterized by the possible clearance of the medial vascular grove. Borderline resectable PDAC patients who retain an increased risk of infiltration to the portomesenteric system and/or arterial vasculate are candidates for neoadjuvant therapy. However, redefined pathological analysis revealed the dorsal resection margin to be similar at risk for R1 resection. Mesopancreatic excision (MPE) aims to secure the integrity of the dorsal and ventral resection margins. The existence of the mesopancreas (MP) is inevitable, since the pancreas is of a secondary retroperitoneal nature and the dorsal as well as ventral fascial coverings define the peripancreatic compartment anatomy. It remains unknown if the MP area is only infiltrated in high-risk PDAC patients or if MPE during pancreatoduodenectomy should be employed for localized PDAC patients as well., Methods: Patients who underwent upfront pancreatoduodenectomy were included. CRM evaluation and analysis of the MP was standardized in all patients. Patients were sub-grouped by the infiltration status of the vascular groove (localized disease: LOC). In LOC patients there was evidently no cancerous infiltration into the medial vascular groove (true + primary resectable)., Results: Two hundred eighty-four consecutive patients who underwent pancreatoduodenectomy were included (169 LOC patients). In LOC patients the MP infiltration rate remained high but was significantly lower when compared to advanced PDAC patients (MP + 69.2% vs. 83.5%, p = 0.005). In LOC patients, CRM resection status of the dorsal resection status remained significantly affected by the MP infiltration status (R0CRM- 80.5% vs. 62.8%, p = 0.019)., Conclusion: These important findings clearly show underestimated tumor extensions into the mesopancreas even in localized, primary resectable PDAC patients who are currently amenable for upfront resection. Synergistically to total mesorectal or mesocolic excision, which is applied to all stages of colorectal disease, MPE is justified in primary resectable patients as well. Therefore, MPE should be employed in all PDAC patients. Since the infiltration status of the mesopancreas was a significant factor for incomplete resection in primary resectable PDAC patients, neoadjuvant treatment options for must be discussed., Competing Interests: Declarations. Ethics approval and consent to participate: This study was conducted in compliance with Good Clinical Practice standards and adhered to the principles outlined in the Declaration of Helsinki. The research protocol received approval from the Institutional Review Board (IRB) of the Medical Faculty at Heinrich Heine University Düsseldorf. The research received approval from the Institutional Review Board (IRB) of the Medical Faculty at Heinrich Heine University Duesseldorf, (IRB-no. 2020–1990, 2019–473, 2019–473-1 and 2019–473-2). A pseudonymization was always guaranteed throughout the project. Patients were informed about the research project and consented to it. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose: The purpose of this study is to evaluate the efficacy of laparoscopic pancreaticoduodenectomy (LPD) with superior mesenteric artery (SMA) left posterior first approach and circumferential lymphadenectomy with total meso-pancreas (MP) dissection for periampullary malignancies., Methods: 31 patients who underwent LPD with left posterior SMA first-approach and circumferential lymphadenectomy with total MP dissection between September 2021 and September 2023. General characteristics, operative techniques, short-term outcomes and pathological results were prospectively evaluated., Results: The mean operation time and SMA first-approach time were 441.9 ± 73.7 min and 99.9 ± 27.7 min, respectively. The median intraoperative blood loss was 143 ml (range: 50-1500 ml). The median number of total LNs and left-sided SMA LNs harvested were 32,7 ± 13 (16-74) and 7,4 ± 6 (range: 3-30), respectively. The rate of metastatic left-sided SMA LNs and meso-pancreas were 25.8% and 22.6%, respectively. 22.6% of patients had pancreatic fistula, but mostly in grade A, with only one case that required conversion. Only one case developed postoperative refractory diarrhea. The mean postoperative hospital stay was 14.1 days. No 90-day mortality was reported., Conclusion: LPD with left posterior SMA first-approach and circumferential lymphadenectomy with total MP dissection was safe and effective with favorable short-term outcomes., Competing Interests: Declarations. Ethics approval and consent to participate: Ethics approval of this study was given by the Research Ethics Committees of Hanoi Medical University. Written informed consent for publication of their clinical details and clinical images was obtained from the patients’ family. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Pancreatectomies combined with arterial resection can be indicated for pancreatic cancer. In a pancreatectomy with arterial resection, intraoperative confirmation of blood flow through reconstructed vessels is crucial. This study highlights the usefulness of SPY laser fluorescence imaging during a pancreatoduodenectomy with common hepatic artery resection (PD-CHAR)., Patient and Methods: A 55-year-old man with borderline resectable pancreatic head cancer underwent a PD-CHAR. After confirming tumor resectability, reconstruction of the CHA to the proper hepatic artery was performed. Subsequently, the superior mesenteric vein was reconstructed., Results: SPY laser fluorescence imaging demonstrated arterial blood perfusion to the liver through the reconstructed hepatic artery, followed by perfusion from the portal vein. The operation lasted 493 min, with an estimated blood loss of 400 mL. The postoperative course was uneventful with good arterial blood flow., Conclusion: The SPY Portable Handheld Imager could be valuable for visualizing blood flow in reconstructed vessels and assessing tissue perfusion during a pancreatectomy combined with vascular reconstruction., Competing Interests: Disclosure: The authors declare that they have no conflicts of interest. Ethics Approval: Ethical approval was not required because this was a single report and not a trial or observational study. Written informed consent was obtained from the patient for the publication of this case report and the accompanying images., (© 2024. The Author(s).)

Background: Robotic pancreaticoduodenectomy (RPD) is used more commonly, but high-level evidence is still scarce. This meta-analysis aimed to compare the short-term outcomes between RPD and laparoscopic pancreaticoduodenectomy (LPD) using data collected from propensity score-matched (PSM) studies., Materials and Methods: We searched PubMed, Cochrane Library, Embase, and Web of Science databases for PSM studies comparing RPD and LPD. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals were calculated., Results: Ten PSM studies were included, encompassing 8106 patients (RPD group: 3695 patients; LPD group: 4411 patients). Compared with LPD, RPD was associated with a lower conversion rate (RR, 0.56) and blood transfusion rate (RR, 0.49), as well as a higher number of harvested lymph nodes (MD, 2.15). There were no significant differences observed in 30-day readmission (RR, 1.02), 90-day mortality (RR, 1.01), overall morbidity (RR, 0.94), major complications (RR, 1.06), operative time (MD, -8.00 min), blood loss (MD, -19.37 mL), reoperation (RR, 0.95), bile leak (RR, 0.93), chylous leak (RR, 1.40), postoperative pancreatic fistula (RR, 1.06), delayed gastric emptying (RR, 0.92), wound infection (RR, 1.12), length of stay (MD, -0.32 days), and R0 resection (RR, 0.98) between the groups., Conclusions: Although LPD and RPD had similar surgical outcomes, RPD had the perioperative advantage over LPD in decreasing conversion rates and blood transfusion rates and increasing the number of lymph nodes harvested. Further randomized controlled trials evaluating the potential advantages of RPD over LPD are warranted., (Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Though open pancreatoduodenectomy (OPD) is the gold standard, robotic pancreatoduodenectomy (RPD) is on the rise due to its technical ease with robotic armamentarium and claim to decrease morbidity in the perioperative period. This study compares the perioperative and oncologic outcomes of RPD performed for periampullary neoplasms (PANs) with OPD., Method: This is a retrospective study conducted from January 2018 to December 2023 for all the patients who underwent either OPD or RPD for PANs. Demographic, peri-operative outcomes and oncological parameters [disease-free survival (DFS) and overall survival (OS)] were analysed and compared. The two groups were matched using 1:1 propensity score matching (PSM) to reduce the risk of confounding., Results: A hundred patients were analysed (30 in RPD and 70 in OPD), and both groups were similar in demographic characteristics. Post-operative morbidity in terms of clinically relevant pancreatic fistula, post-pancreatectomy haemorrhage, delayed gastric emptying and overall Clavien-Dindo ≥ Grade 3 complications were similar in both groups. Surgical site infection (SSI) was significantly higher in the OPD group compared to RPD (31.4% vs. 6.7, p = 0.008); however, the median postoperative hospital stay was similar in both groups. After PSM (26 patients in each group), the RPD group had significantly more operative time (480 min vs. 360 min, p = 0.007) less blood loss (250 ml vs. 400 ml, p = 0.004), and similar SSI [2(7.7%) vs. 6(23.1%), p = 0.178). The R0 resection rate, lymph nodal yield, lymph nodal positivity, DFS and OS were similar in both groups., Conclusion: The robotic approach for PD is technically safe and feasible with equivalent resection quality and oncological outcomes compared to the open approach. RPD has equivalent postoperative morbidity, DFS and OS., Competing Interests: Declarations. Disclosures: Drs. Vaibhav Kumar Varshney, Kaushal Singh Rathore, Selvakumar B, Subhash Soni, Peeyush Varshney, Lokesh Agarwal, Akhil Dhanesh Goel and Abhishek Jaiswal declare that they have no conflicts of interest or financial ties to disclose., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Overweight is thought to affect the outcome of minimally invasive surgery. There is still a lack of controlled studies of laparoscopic pancreaticoduodenectomy (LPD) versus open pancreaticoduodenectomy (OPD) in overweight patients. This study was designed to compare short-term and long-term outcomes in overweight patients treated with LPD and OPD., Methods: Clinical and follow-up data on overweight patients who received LPD or OPD at Shandong Provincial Hospital from January 2015 to December 2022 were analyzed retrospectively. The bias between groups were balanced by 1:1 propensity score matching (PSM). Kaplan-Meier survival curves described long-term survival outcomes in overweight pancreatic ductal adenocarcinoma (PDAC) patients., Results: A total of 502 overweight patients were enrolled in the study. There were 276 patients in the LPD group and 226 in the OPD group. After matching, 196 patients were enrolled in each group. Compared with the OPD group, the LPD group had fewer estimated blood loss (EBL) (140 vs. 200 mL, P < 0.001), more lymph node dissection (14 vs. 12, P = 0.010), and shorter postoperative length of stay (LOS) (13 vs. 16 days, P < 0.001). There were no significant differences in severe complications, 90-day readmission and mortality rates (all P > 0.05). The subgroup analysis of obese patients also showed that the LPD group had fewer intraoperative EBL, more lymph node dissection, and shorter LOS. The survival analysis showed that overweight patients with PDAC who underwent LPD or OPD had similar overall survival (OS) (23.8 vs.25.7 months, P = 0.963) after PSM., Conclusion: It is safe and feasible for overweight patients undergoing LPD to have less EBL, more lymph node harvesting, and a shorter LOS. There was no statistically significant difference in long-term survival outcomes among overweight PDAC patients between the two approaches., Competing Interests: Declarations. Disclosures: Dr. Shuai Xu, Yinlong Xu, Shulin Wang, Qingsen Chu, Huating Zhang, Wei Gong, Yantian Xu, and Jun Liu have no conflicts of interest or financial ties to disclose. Ethical approval: This study was approved by the Medical Ethics Committee of Shandong Provincial Hospital (No.2022-178). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all patients., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Mesopancreas dissection (MPD) level 3 in combined robotic/open pancreatoduodenectomy (CR/OPD) is technique-demanding. This study aims to clarify the feasibility and justification of MPD level 3., Methods: Propensity score matching (PSM) analysis was conducted for 208 patients with pancreatic head cancer undergoing CR/OPD with or without MPD level 3. The comparison focused on surgical and oncological outcomes., Results: After PSM, each group comprised 86 patients. Surgical outcomes were comparable between these two groups, except longer operation time for MPD level 3 (+), median: 10.5 vs. 9.5 h, p = 0.002. MPD level 3 (+) group exhibited higher lymph node yield, median: 20 vs. 17, p < 0.001, and curative (R0) resection rate, 89.5% vs. 69.8%, p = 0.001, compared to MPD level 3 (-) group. Among the entire cohort, no significant survival difference was observed between the MPD Level 3 (+) and (-) groups. Survival outcome for R0 resection after CR/OPD was notably better than those for R2 resection, 5-year survival: 34.0% vs. 0, p = 0.038. However, within the curative (R0) resection cohort, no survival difference was observed between the MPD level 3 (+) and MPD level 3 (-) groups., Conclusion: MPD level 3 in CR/OPD is technically feasible without increasing the surgical risks but takes one hour extra operating time. Incorporation of MPD level 3 does not confer a survival advantage within the curative (R0) resection cohort. The primary focus should continue to be on achieving curative (R0) resection to maximize the survival benefits for pancreatic head cancer., Competing Interests: Declarations. Disclosures: All authors, Bor-Shiuan Shyr, Shin-E Wang, Shih-Chin Chen, Yi-Ming Shy, Bor-Uei Shyr, have no conflicts of interest or financial ties to disclose., (© 2024. The Author(s).)

Background: High morbidity and mortality make pancreaticoduodenectomy (PD) one of the most complicated surgical procedures. This meta-analysis aimed to compare the outcomes of robotic pancreaticoduodenectomy (RPD) versus open pancreaticoduodenectomy (OPD)., Method: A comprehensive literature search of PubMed, Cochrane Central, and Google Scholar was conducted from inception to November 2024. Studies comparing RPD and OPD in adults aged ≥ 18 years were included. Data for the outcomes of interest were extracted., Results: Forty-one studies with a total of 54,287 patients were pooled. RPD is significantly superior to OPD in terms of overall postoperative complications (RR = 0.91, 95% CI: [0.86-0.97]; p = 0.001), wound infections (RR = 0.63, 95% CI: [0.49-0.81], p = 0.0004), estimated blood loss (WMD = -171.99 ml, 95% CI: [ -217.76 to -126.22], p < 0.01) and hospitalization duration (WMD = -1.33 days, 95% CI: [ -1.84 to -0.82], p < 0.01) with a longer operating time (WMD = 73.22 min, 95% CI: [56.20 to 90.23], p < 0.01)., Conclusion: In conclusion, RPD shows a lower risk of wound infections and overall postoperative morbidity compared to OPD. It has lower estimated blood loss, shorter hospitalization duration, and a longer operating time. The two approaches were comparable in terms of resection quality. More high-quality RCTs are required to draw definite conclusions., Competing Interests: Declarations. Ethical Approval: Not Applicable. Informed Consent: Not Applicable. Consent to Publish: Not Applicable. Competing Interest: The authors declare no competing interests., (© 2025. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background/objectives: The aim was to investigate the association between variations in the dorsal pancreatic artery (DPA) and intrapancreatic arcade anatomy with Whipple procedure outcomes and postoperative complications., Methods: This retrospective study was conducted with 362 patients who underwent a Whipple procedure at the Department of Gastroenterological Surgery of Adana City Training and Research Hospital between January 2018 and April 2024. All data collected from medical records were compared and statistically analyzed according to the patients' survival status and arcade subtypes., Results: After excluding cases that did not meet the study criteria, a total of 284 patients were included in the study. DPA was visualized in 55.98% (159/284) of patients, while the intrapancreatic arcade was observed in 25% (71/284). The most common origin of the DPA was the splenic artery in 69.2% (n = 110) of patients, followed by the superior mesenteric artery in 17.6% (n = 28). The frequency of intrapancreatic arcade anatomy variations was as follows: type 1: 28.2% (n = 20), type 2: 49.3% (n = 35) and type 3: 22.5% (n = 16). Arcade type 4 anatomy was not detected. Postoperative pancreatic fistula (POPF) complication was found to be statistically significantly higher in patients with type 3 anatomy ( p = 0.042). The 90-day mortality and long-term mortality rates did not differ among the groups based on the variations in both DPA and intrapancreatic arcade anatomy types., Conclusions: Patients with intrapancreatic arcade type 3 anatomy had a higher risk of POPF complications. Determination of preoperative arcade type by computed tomography (CT) angiography may help to predict the risk of POPF.

The Arc of Bühler (AoB) is a rare anatomical variant in gastrointestinal vasculature where there is an aberrant anastomotic vessel between coeliac and superior mesenteric arteries. We present a rare case where AoB was noted intraoperatively to have haemodynamically significant flow in the context of coeliac artery stenosis, supplementing arterial supply to the hepatic artery proper via the gastroduodenal artery (GDA). An interpositional jump graft between the aorta and the GDA stump was created using the long saphenous vein, and flow was restored. The patient recovered well postoperatively. This case highlights the importance of understanding variations in gastrointestinal vasculature and the role of preoperative planning., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: Pancreatoduodenectomy in elderly patients may be associated with increased postoperative mortality, but studies in minimally invasive pancreatoduodenectomy (MIPD) are scarce., Methods: International multicenter retrospective study including patients aged >60 years undergoing MIPD (robot-assisted and laparoscopic) and open pancreatoduodenectomy (OPD), were categorized by age: 60-69, 70-79, and 80+ years. In each category, propensity score matching (PSM) was performed (1:1 ratio) between MIPD and OPD. Primary outcome was 30-day/in-hospital mortality., Results: Among 3820 patients, we matched 1468 patients aged 60-69, 1154 patients aged 70-79, and 196 patients aged 80+ years. In patients aged 60-69 and 70-79 years, MIPD was associated with longer operative time, less blood loss and a longer length of stay. Major morbidity was higher after MIPD with similar 30-day/in-hospital mortality. The R0 resection rate was higher after MIPD. In patients aged 80+ years, besides a longer operative time in MIPD, outcomes were comparable between both groups., Conclusion: This study found no evidence that increasing age worsens mortality of MIPD. MIPD was associated with longer operative time, higher rate of major morbidity, prolonged length of stay versus less blood loss and a higher R0 resection in patients aged 60-69 and 70-79 years. These differences continue in patients aged 80+ years, but became less evident., Competing Interests: Conflict of interest LRJ and MGB received funding from the Intuitive Surgical® for the investigator-initiated LEARNBOT study on safe implementation and training of robot pancreatoduodenectomy in Europe. MGB and MAH received funding from Intuitive Surgical® (LEARNBOT 24445; DIPLOMA-2 24904) and Ethicon EndoSurgery (994492729) to support the ongoing quality registry for minimally invasive pancreatic surgery in Europe and from Intuitive Surgical® for the investigator-initiated DIPLOMA-2 randomized trial comparing minimally invasive and open pancreaticoduodenectomy. The other authors have nothing to disclose relevant to this study or manuscript., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Annular pancreas is a rare congenital anatomical anomaly, in which the pancreatic parenchyma surrounds the descending duodenum. Generally, annular pancreas is diagnosed on the basis of symptoms associated with complications of peptic ulcer, pancreatitis, cholelithiasis, and rarely, malignant tumors. Herein, we report an 84-year-old man for whom, during hospitalization for a urinary tract infection, pancreatic cystic lesions and an annular pancreas were noted incidentally on computed tomography. These findings led to a diagnosis of intraductal papillary mucinous neoplasms on further examination. He safely underwent robot-assisted pylorus-preserving pancreatoduodenectomy, with an operative time of 478 min and blood loss of 37 g. He was discharged on postoperative day 8 without postoperative complications. In conclusion, it is important to note that, in this case, intraductal papillary mucinous neoplasms were detected before they became malignant, and minimally invasive surgery was performed safely despite the anatomical anomaly of an annular pancreas., (© 2025 The Author(s). Asian Journal of Endoscopic Surgery published by Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Background/aim: To investigate risk factors of late acute remnant pancreatitis after pancreatoduodenectomy (PD), we propose the use of a suturing pitch calculated based on the diameter of the main pancreatic duct and the number of sutures used in the pancreatic duct-to-mucosa anastomosis. This study aimed to determine whether the suturing pitch can predict late acute pancreatitis following PD., Patients and Methods: This study included 142 patients who underwent elective PD. The suturing pitch was defined as the distance between the ligations of the duct-to-mucosa anastomosis of the pancreatojejunostomy. It was calculated using the formula: main pancreatic duct size × π ÷ suturing number. Late acute pancreatitis was defined as acute pancreatitis occurring more than 30 days after PD. We retrospectively evaluated clinical parameters, including the suturing pitch, to identify predictors of late acute remnant pancreatitis., Results: Late acute remnant pancreatitis occurred in seven patients, and the 5-year and 10-year cumulative incidence rates were 8.5% and 12.7%, respectively. A narrow suturing pitch was significantly associated with male sex (p=0.037), younger age (p=0.003), soft pancreas (p<0.001), narrow pancreatic duct stent size (p<0.001), narrow main pancreatic duct size (p<0.001), and the occurrence of late acute remnant pancreatis (p=0.006). In multivariate analysis, the narrow suturing pitch was a significant and independent risk factor of late acute remnant pancreatitis (p=0.041), but not of postoperative pancreatic fistula (p=0.106)., Conclusion: To prevent late acute remnant pancreatitis, the pancreatic duct-to-mucosa anastomosis should not be sutured too tightly., (Copyright © 2025 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Compared to open pancreaticoduodenectomies (OPD), the robotic (RPD) approach decreases the rate of complication and the length of stay (LOS). However, it remains unknown if these benefits persist in octogenarians, who are at higher risk for perioperative morbidity and mortality., Methods: A retrospective analysis of the ACS-NSQIP database was performed to identify patients aged 80 years or older who underwent PD for pancreatic adenocarcinoma between 2015-2021. Patients who underwent RPD or OPD were compared using inversed probability weighting of the propensity score. Outcomes assessed include operative time, LOS, non-home discharge, major complications, unplanned readmission, return to the operating room, mortality, and clinically relevant postoperative pancreatic fistula., Results: Of 30,751 patients, 1720 were octogenarians. One thousand six hundred twenty-five patients (94 %) underwent OPD, and 95 (6 %) underwent RPD. RPD was significantly associated with a reduced incidence of major complications (32.6 % vs. 45.6 %; p < 0.01) and a lower rate of non-home discharge (24.7 % vs. 34.3%; p < 0.05). However, RPD was associated with a longer operative time (438 min vs. 342 min; p < 0.0001). There was no difference in other assessed outcomes., Conclusion: RPD may reduce major postoperative complications and non-home discharges compared to the open approach for octogenarians., (Copyright © 2024 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Purpose: The retroperitoneal nature of the pancreas, marked by minimal intraoperative organ shifts and deformations, makes augmented reality (AR)-based systems highly promising for pancreatic surgery. This study presents preliminary data from a prospective study aiming to develop the first wearable AR assistance system, ARAS, for pancreatic surgery and evaluating its usability, accuracy, and effectiveness in enhancing the perioperative outcomes of patients., Methods: We developed ARAS as a two-phase system for a wearable AR device to aid surgeons in planning and operation. This system was used to visualize and register patient-specific 3D anatomical models during the surgery. The location and precision of the registered 3D anatomy were evaluated by assessing the arterial pulse and employing Doppler and duplex ultrasonography. The usability, accuracy, and effectiveness of ARAS were assessed using a five-point Likert scale questionnaire., Results: Perioperative outcomes of five patients underwent various pancreatic resections with ARAS are presented. Surgeons rated ARAS as excellent for preoperative planning. All structures were accurately identified without any noteworthy errors. Only tumor identification decreased after the preparation phase, especially in patients who underwent pancreaticoduodenectomy because of the extensive mobilization of peripancreatic structures. No perioperative complications related to ARAS were observed., Conclusions: ARAS shows promise in enhancing surgical precision during pancreatic procedures. Its efficacy in preoperative planning and intraoperative vascular identification positions it as a valuable tool for pancreatic surgery and a potential educational resource for future surgical residents., Competing Interests: Declarations. Conflict of interest: The authors have no competing interests to declare that are relevant to the content of this article. Ethical approval: The study protocol was approved by the Ethics Committee of the Medical Association of Saarland (registration number: 159/23)., (© 2024. The Author(s).)

Purpose: Although laparoscopic pancreaticoduodenectomy (LPD) and robot-assisted pancreaticoduodenectomy (RPD) are gradually gaining popularity, their advantages over open pancreaticoduodenectomy (OPD) remain controversial. This study aimed to compare the short-term outcomes of OPD, LPD, and RPD to elucidate the advantages and disadvantages of each procedure., Methods: We retrospectively analyzed 16 LPD, 43 RPD, and 36 OPD procedures performed at a single center between April 2020 and May 2024. Clinical data, including operative time, estimated blood loss, postoperative complications, length of hospital stay, and hospitalization costs, were retrospectively collected and analyzed., Results: RPD demonstrated a significantly longer operative time (553 min) than OPD (446 min) and LPD (453 min) but a significantly lower estimated blood loss than OPD (150 mL vs. 400 mL, p < .001). Postoperative complication rates (Clavien-Dindo grade ≥3) were lower for RPD (24.4%) than those for OPD (50.0%) and LPD (68.8%). RPD also showed a significantly lower rate of clinically relevant postoperative pancreatic fistula (14.6% vs. 38.9% for OPD and 43.8% for LPD) and a shorter duration of hospitalization (11 vs. 28 days for OPD and 21 days for LPD, p < .001). Hospitalization costs were higher for RPD (20 109 USD) than for OPD (18 487 USD, p < .001), with LPD (20 496 USD) and RPD costs being similar., Conclusions: RPD appears to offer advantages in terms of reduced blood loss and postoperative complications and shortened hospital stay despite longer operative times and higher hospitalization costs. Therefore, RPD may be a more beneficial approach than OPD or LPD in pancreatic surgery., (© 2024 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Objective: To analyze the incidence, clinical manifestations and treatment of post-pancreaticoduodenectomy hemorrhage in patients with pancreaticoduodenal tumors., Material and Methods: There were 362 pancreaticoduodeneectomies for ductal adenocarcinoma of the pancreatic head and pancreatoduodenal tumors in 2016-2023. Post-pancreatectomy hemorrhage (PPH) occurred in 52 (14.4%) patients. Delayed post-pancreatectomy hemorrhage followed postoperative pancreatitis, pancreatic fistula or non-drained fluid collections. Bleeding was diagnosed considering clinical manifestations with verification through contrast-enhanced CT., Results: Emergency re-laparotomy was required in 15 (28.8%) patients with unstable hemodynamics; 9 (60%) people died. Thirty-seven patients with stable hemodynamics underwent emergency contrast-enhanced CT and subsequent endovascular hemostasis. Bleeding was stopped in 31 patients (89.2%). Endovascular hemostasis was ineffective in 1 patient who underwent re-laparotomy. We found no the cause of bleeding in 3 patients, and there was no hemorrhage recurrence. Six (18.7%) people died. The overall mortality among patients with PPH was 28.8% (15 out of 52 postoperative patients)., Conclusion: PPH follows postoperative pancreatitis, pancreatic fistula or non-drained fluid collection. In case of stable hemodynamics, endovascular hemostasis is preferable for this complication.

Background: To evaluate recent minimally invasive pancreatectomy (MIP) trends for neoplastic disease and compare perioperative outcomes., Methods: Patients who underwent open (OS) or MIP (laparoscopic-LS or robotic-RS) pancreaticoduodenectomy (PD) or non-pancreati-coduodenectomy resections (non-PD) were identified from PINC AI Healthcare Database. Outcomes were compared using multivariable regressions., Results: OS was the predominant approach for PD (87.8%); MIP was more common in non-PD (48.5%) than PD with a substantial RS uptake (11.7%-29.9%). In PDs, outcomes were similar except OS had a longer length of stay (LOS) and lower costs. In non-PDs, MIP patients were less likely to have prolonged LOS, intensive care unit admission, and overall complications than OS. Conversion to OS was lower in the RS approach than LS in PD and non-PD., Conclusions: MIP for non-PD has become the most common operative approach with improved outcomes; MIP-PD has flat adoption and similar outcomes to OS. Robotics facilitates MIP (PD and non-PD) completion through fewer conversions to open surgery (OS)., (© 2024 Intuitive Surgical and The Author(s). World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Objective: To research the features of endoscopic treatment of choledocholithiasis and biliary strictures in patients with surgically altered anatomy of the upper gastrointestinal tract., Material and Methods: A single-center retrospective study included 19 consecutive patients. Early outcomes including: the success of intubation of the afferent limb, the success of selective cannulation of the biliary ducts, the effectiveness of the performed operations; the frequency of complications; factors related to these indicators., Results: 3 (15.7%) patients failed intubation of the afferent limb. In 16 (84.2%) patients, endoscopic treatment was an effective final treatment method - regression of obstructive jaundice was achieved and cholangitis was stopped. 9 (69.2%) of 13 patients with choledocholithiasis, complete one-stage stone extraction was performed; 4 (30.8%) patients staged treatment was performed, during which 3 patients underwent cholangioscopy procedure with lithotripsy (laser and electrohydraulic). 3 patients with benign strictures underwent staged endoscopic treatment - multiple procedures to upsize and number of stents. In 1 (6.3%) 85-year-old patient with choledocholithiasis complicated by cholangitis and abscesses, surgery and complex therapy did not avoid a fatal outcome. There were no other complications., Conclusion: Endoscopic treatment of choledocholithiasis and biliary strictures in patients with surgically altered anatomy is a more difficult task. In a significant proportion of patients endoscopic treatment is effective. The success of the endoscopic treatment is due to the equipment of the hospital and the skills of physicians. It may be advisable to concentrate this technique in a centres with skill and expertise.

Purpose: Postpancreatectomy hemorrhage (PPH) is a life-threatening complication after pancreatoduodenectomy. Stent-graft implantation is an emerging treatment option for PPH. This study reports the outcome of PPH treated with stent-graft implantation., Methods: This was a single-center, retrospective study. Between April 2020 and December 2023, 1723 pancreatectomy cases were collected while we screened 12 cases of PPH after pancreatoduodenectomy treated with stent-graft implantation. Patients' medical and radiologic images were retrospectively reviewed. Technical and clinical success, complications, and stent-graft patency were evaluated. Continuous data are reported as means ± standard deviation when normally distributed or as median (Q 1 , Q 3 ) when the data is non-normal distributed. Categorical data are reported as n (%). A p < 0.05 was considered statistically significant. Kaplan-Meier estimates were used for stent patency and patients' survival., Results: Pancreatic fistula was identified in 6 cases (50.0%), and pseudoaneurysm was identified in 3 cases (25.0%), including pancreatic fistula together with pseudoaneurysm in 1 case (8.3%). All pseudoaneurysm or contrast extravasation sites were successfully excluded with patent distal perfusion, thus technical success was achieved in all cases. The overall survival rate at 6 months and 1 year was 91.7% and 78.6%, respectively. One patient had herniation of the small intestine into the thoracic cavity, which caused a broad thoracic and abdominal infection and died during hospitalization. Rebleeding occurred at the gastroduodenal artery stump in 1 case after stent-graft implantation for the splenic artery and was successfully treated with another stent-graft implantation. Two cases of asymptomatic stent-graft occlusion were observed at 24.6 and 26.3 after the operation, respectively., Conclusions: With suitable anatomy, covered stent-graft implantation is an effective and safe treatment option for PPH with various bleeding sites and causes., Competing Interests: Declaration of competing interest There is no conflict of interest or funding to disclosure., (Copyright © 2024 Chinese Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: This study compared short- and mid-term outcomes of hemihepatectomy (HH) and pancreatoduodenectomy (PD) in patients with extrahepatic cholangiocarcinoma, focusing on surgical outcomes, body composition, and nutritional status., Method: A retrospective review was conducted to assess short-term outcomes, including operative time, blood loss, complications, and mortality. Body composition and nutritional parameters were analyzed preoperatively and 1 year postoperatively. Multivariate analysis identified factors influencing outcomes., Result: Among 216 patients (HH: n = 94, PD: n = 122), HH was associated with younger age (median 72 vs. 74 years, p = 0.041), longer operative times (p = 0.008), and greater blood loss (p < 0.001) compared to PD. Despite this, HH had fewer severe complications (42.6% vs. 75.4%, p < 0.001), lower rates of pancreatic fistula (5.3% vs. 60.7%, p < 0.001), and shorter postoperative hospital stays (p = 0.002). Mortality occurred in 3 HH patients (3.2%), all of whom underwent right hemihepatectomy, compared to none in PD (p = 0.081). One year postoperatively, HH patients had better preservation of skeletal muscle area (p = 0.139), body fat area (p = 0.319), and hemoglobin levels (p = 0.060) compared to significant declines observed in PD patients (all p < 0.001). Multivariate analysis indicated that HH was independently associated with better preservation of skeletal muscle area (β = 2.58, p < 0.001), body fat area (β = 20.86, p < 0.001), and hemoglobin levels (β = 0.81, p = 0.009) at one year postoperatively., Conclusion: HH was associated with better preservation of physical and nutritional status compared to PD. However, the higher perioperative mortality observed in HH, particularly right hemihepatectomy, necessitates careful consideration of the risks and benefits when selecting the surgical approach for patients with extrahepatic cholangiocarcinoma., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Preoperative biliary drainage (PBD) for selected patients with severe juandice has been shown to improve clinical conditions for pancreaticoduodenectomy (PD) and reduce the risk of post-pancreatectomy hemorrhage (PPH). However, the determination of an optimal end-point for PBD remains unclear. The aim of this research is to introduce the concept of goal-oriented biliary drainage, which may serve as a reasonable target and identify the optimal surgery time window., Methods: The clinical data of 194 patients diagnosed with pancreatic cancer and obstructive jaundice were retrospectively analyzed. Serological laboratory examinations including total bilirubin (TBIL) within one week before PBD and PD were recorded and labeled as TBIL-pre and TBIL-post respectively. PBD and PD were performed by experienced medical teams. PPH with grade B and C were enrolled., Results: TBIL-post less than 93.0µmol/L (sensitivity 83.78%, specificity 72.61%) or TBIL decay more than 68.5% (sensitivity 86.49%, specificity 69.43%) identified through ROC curves and multivariate analysis were independent protective factors for reducing the risk of PPH (OR 0.234 and 0.191 retrospectively, P<0.05) and were established as PBD goals. The Kaplan-Meier curves demonstrated the median time to achieve both PBD goals was 3 weeks. Additionally, the proportion of patients achieving both goals failed to increase with the PBD duration over 6 weeks (P > 0.05). The proportion of TBIL-post ≤ 93.0µmol/L (70.8% vs. 51.1%, P<0.05) and TBIL decay ≥ 68.5% (67.0% vs. 50.0%, P<0.05) were higher in EBS group than those in PTCD group., Conclusion: A goal-oriented PBD with the target of TBIL ≤ 93.0µmol/L or TBIL decay ≥ 68.5% can reduce the morbidity of PPH. In general conditions, PBD duration within 3 weeks would be sufficient, while exceeding the duration beyond 6 weeks could not provide additional benefits. Both EBS and PTCD are safe and EBS is more recommended due to its superior performance in achieving the goals., Competing Interests: Declarations. Ethics approval and consent to participate: This study is approved by Ethics Committee of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China. The ethics approval number is I-23PJ1360. This observational study utilizes only clinical data for statistical analysis and does not disclose any personal information or privacy-related details from the patient as granted Waiver of informed consent from the ethical approval. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Robotic platforms are increasingly utilized in surgery, offering unique technical advantages, though there is a scarcity of difficulty scoring systems (DSS) for these procedures. DSS aids in understanding operative complexities and enhancing preoperative planning. With IRB approval, data were collected on 200 consecutive adult patients who underwent robotic pancreaticoduodenectomy at a high-volume institution from 2019 to 2022. Linear regression was employed on clinical variables to analyze operative time and estimated blood loss as markers of surgical complexity. Weighted scoring system was developed using significant linear coefficient values, and an ANOVA analysis created the difficulty-level grouping system. Significant variables affecting operative time and/or EBL included: history of alcoholism, preoperative endoscopic intervention, tumor size, nodal disease on preoperative imaging, pancreatic duct dilation. These factors created the DSS ranging from 0 to 33. Group 1 (0-8, n = 9), Group 2 (9-20, n = 145), Group 3 (21-26, n = 37), and Group 4 (27-33, n = 9) showed significant differences in age, history of alcoholism, preoperative jaundice, tumor size, nodal disease, and operative metrics. Our novel DSS for robotic pancreaticoduodenectomy effectively predicts intraoperative challenges and aids in preoperative planning. Future steps include validating the system internally and externally., Competing Interests: Declarations. Conflicts of interest: Michelle M. Dugan, Iswanto Sucandy, Alexander Rosemurgy, Maria Christodoulou, Tara M. Pattilachan, Sneha Saravanan, Shlomi Rayman and Harel Jacoby have no conflicts of interest or financial ties to disclose. Dr. Sharona Ross is a consultant for Intuitive Surgical (Sunnyvale, CA) and Ethicon (Cincinnati, OH). Dr. Sharona Ross receives educational grants for her Women in Surgery Career Symposium from Intuitive Surgical and Medtronic (Minneapolis, MN)., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

This study sought to identify the primary reasons for hospital readmissions and examine patient outcomes and associated costs following readmission after robotic pancreaticoduodenectomy. We conducted a retrospective analysis of 435 patients who underwent robotic pancreaticoduodenectomy between 2012 and 2024. Readmitted patients within 30 days post-surgery were compared to non-readmitted patients using Student's t-test and Fisher's exact test. Data are presented as median (mean ± SD). In the study cohort, 86 patients (20%) were readmitted within 30 days after surgery. No significant differences were found in patient demographics or outcomes. The most common causes for readmission included insufficient patient education (n = 18), infection (n = 16), and gastrointestinal bleeding (n = 13). The readmitted cohort had significantly higher costs at $40,452 (± 30,724) compared to $31,438 (± 31,546.2) for non-readmitted patients (p < 0.001). Median survival was similar between the two groups (36 vs. 34 months, p = 0.88). Although some readmissions are inevitable, this study provides compelling evidence that inadequate patient education is a primary contributor to increased healthcare costs. The lack of sufficient education appears to have no mitigating effect on patient outcomes. Implementing a proactive, thorough patient education approach, combined with improved emergency department awareness, presents a promising strategy for reducing costly readmissions., Competing Interests: Declarations. Conflict of interest: Denis Gratsianskiy, Dharti Patel, Iswanto Sucandy, Alexander Rosemurgy, Maria Christodoulou, Tara M. Pattilachan have no conflicts of interest or financial ties to disclose. Dr. Sharona Ross is a consultant for Intuitive Surgical (Sunnyvale, CA) and Ethicon (Cincinnati, OH). Dr. Sharona Ross receives educational grants for her Women in Surgery Career Symposium from Intuitive Surgical and Medtronic (Minneapolis, MN)., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Mixed neuroendocrine-non-neuroendocrine tumors (MiNEN) are a rare type of tumor formed by two components, a non-neuroendocrine component that is most often an adenocarcinoma and a neuroendocrine tumor, and each of these components must represent at least 30% of the tumor. The origin of this tumor on the ampulla of Vater or periampullary region is more infrequent. Usually, the lesions are highly aggressive and quickly metastasizing, and their biological behavior is dictated by the high grade of the neuroendocrine component. This is the first report of a patient with ampullary MiNEN treated employing a robotic pancreaticoduodenectomy. Although being submitted to aggressive treatment with complete surgical resection followed by systemic therapy, the patient developed early recurrence with hepatic metastatic disease, demonstrating the hostile nature of these tumors.

Management of intrahepatic cholangiocarcinoma relies on a thorough understanding of the tumor's location and proximity to critical vasculobiliary structures. Mid-common bile duct tumors may require hemihepatectomy or pancreatoduodenectomy based on the status of the intraoperative frozen section. Distal common bile tumors are treated with pancreatoduodenectomy. When appropriate, volumetric assessment of the remnant liver should be performed to identify cases requiring preoperative liver augmentation strategies. A similar strategy should be employed for perihilar tumors, which require a right trisegmentectomy with bilioenteric reconstruction to achieve a negative margin. Adjuvant systemic therapy is recommended and increasing usage of neoadjuvant treatment is being incorporated into borderline resectable or regionally advanced cases., Competing Interests: Disclosure There are no financial disclosures or conflicts of interest for either author to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Laparoscopic pancreaticoduodenectomy (LPD) with superior mesenteric/portal vein (SMV/PV) resection and reconstruction was the most technically challenging procedure and had been rarely reported. However, single-incision plus one-port LPD (SILPD +1) with SMV/PV resection and reconstruction has never been reported. In this study, we will demonstrate the feasibility, safety, key surgical procedure, and long-term outcomes for SILPD +1 with SMV/PV resection and reconstruction using video evidence. Two cases of SILPD +1 with SMV/PV wedge resection were carried out by the authors. There was no tumor recurrence during the one-year follow-up. It is worth noting that skilled laparoscopic technicians are necessary to safely complete the procedure with good short-term and long-term outcomes., (Copyright © 2024 Asian Surgical Association and Taiwan Society of Coloproctology. Published by Elsevier B.V. All rights reserved.)

Competing Interests: The authors declare that they have no conflict of interest.

Upper gastrointestinal tumors, including ampullary adenomas, occur frequently in patients with familial adenomatous polyposis (FAP). Guidelines recommend upper gastrointestinal endoscopy in FAP for surveillance of gastric and duodenal adenomas. However, adenomas can rarely arise from biliary epithelium in patients with FAP. Here, we describe a case of tubular adenoma at the hepatico-jejunal anastomosis with intraductal extension in a patient with FAP and previous pancreaticoduodenectomy. This report illustrates a unique case and emphasizes the need for data on postoperative surveillance in patients with FAP, particularly following pancreaticoduodenectomy., (© 2024. Japanese Society of Gastroenterology.)

Purposes: The optimal surgical technique and perioperative management to prevent postoperative pancreatic fistula (POPF) formation after pancreaticoduodenectomy have not yet been established. This study examined the perioperative outcomes of pancreaticogastrostomy with endoscopic transgastric drainage., Methods: We performed a retrospective analysis of 191 patients who underwent pancreaticoduodenectomy between 2016 and 2023. They were divided into two groups: pancreaticojejunostomy group (n = 135) and pancreaticogastrostomy group (n = 56). We compared preoperative factors and postoperative outcomes. We performed endoscopic drainage only in the pancreaticogastrostomy group., Results: Preoperative factors were similar between the two groups. Operative time [480 (404-542) vs. 382 (346-458) minutes], blood loss [505 (270-850) vs. 315 (145-535) g], pseudoaneurysm formation (7 % vs. 0 %), and postoperative hospital stay [28 (22-38) vs. 19 (17-24) days] were significantly lower in the pancreaticogastrostomy group. In the analysis of 41 patients with POPF, postoperative hospital stay [40 (23-108) vs. 27 (18-54) days] and hospital stay after POPF diagnosis [30 (10-99) vs. 15 (5-35) days] were significantly shorter in the pancreaticogastrostomy group. Endoscopic transgastric drainage was performed in 77 % of patients in the pancreaticogastrostomy group, and drainage was successfully completed in all patients., Conclusion: Pancreaticogastrostomy with endoscopic transgastric drainage could be effective for the safe management of pancreaticoduodenectomy., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Competing Interests: The authors declare that they have no conflict of interest.

Background: Robotic pancreatoduodenectomy is an increasingly accepted alternative for the treatment of pancreatic ductal adenocarcinoma (PDAC). 1 However, the ability to perform a meticulous robotic-assisted superior mesenteric artery (SMA) dissection to obtain a margin-negative resection remains unknown. 2 PDAC within the head of the pancreas (HOP) that involves the superior mesenteric vein (SMV) and portal vein (PV) requires total venous control (TVC) and a 'vein-to-the-right' (or anterior artery-first) approach to SMA dissection to minimize venous congestion and operative blood loss. 3-5 Here, we demonstrate a robotic pancreatoduodenectomy with TVC and a 'vein-to-the-right' approach., Methods: A 70-year-old woman with cT2N0M0 HOP PDAC with lateral SMV involvement and right gastroepiploic vein occlusion underwent robotic pancreatoduodenectomy after neoadjuvant chemotherapy. After transecting the pancreas, we achieved TVC by dividing the small venous tributaries and encircling the SMV, splenic vein, and PV. We then proceeded with a 'vein-to-the-right' approach. The inferior pancreatoduodenal arteries were divided to minimize HOP inflow and decrease specimen bleeding. Once the specimen was dissected off the periadventitial plane of the distal SMA, the SMV dissection was carefully performed using a partial side-wall vein resection using a vascular stapler., Results: Total operative time was 7.5 h and estimated blood loss was 25 mL. The patient recovered well postoperatively and was discharged on postoperative day 3. Final pathology exhibited a 2.4 cm, moderately to poorly differentiated adenocarcinoma with negative margins (ypT2N1, 2/38 lymph nodes positive)., Conclusion: For tumors with lateral vein involvement, robotic pancreatoduodenectomy can be safely performed via TVC and a 'vein-to-the-right' approach., (© 2024. Society of Surgical Oncology.)

Background: Adoption of robotic pancreatoduodenectomy (RPD) is growing, although there are challenges for safe introduction of this technique, including limitations in on-site expert proctoring. We developed and implemented a structured approach for safe introduction of a new RPD program using virtual collaboration., Methods: A structured framework for introducing a RPD program was designed; key steps included obtaining additional training, identifying required resources, establishing a dedicated team, and patient safety considerations. Virtual collaboration with a proctor for bidirectional communication was utilized for remote operative guidance. In the initial cohort, perioperative data and postoperative outcomes were extracted from a prospectively maintained database., Results: From August 2020 to December 2023, 68 patients underwent RPD. The median operative time was 407 min with an estimated blood loss of 150 mL. Median length of stay was 8 days. Negative margins were obtained in 90% of resections. Operative time was significantly shorter in the second half of cases compared to the first (380min vs 441min, p < 0.01) and rate of conversion decreased (6% vs 21%)., Conclusion: The safe initiation of a structured RPD program is feasible through virtual expert collaboration. With careful consideration and an appropriate environment, excellent perioperative outcomes are achievable even for initial cases., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Robotic pancreatoduodenectomy is increasingly being implemented worldwide, with good results reported from individual expert centers. However, it is unclear to what extent outcomes will continue to improve during the learning curve, as large international studies are lacking., Methods: An international retrospective multicenter case series, including consecutive patients after robotic pancreatoduodenectomy from 18 centers in 8 countries in Europe, Asia, and South America until December 31, 2019, was conducted. A cumulative sum analysis was performed to determine the inflection points for the feasibility (operative time and blood loss) and proficiency (postoperative pancreatic fistula grade B/C and major morbidity) learning curves. Outcomes were compared in 3 groups on the basis of the learning curve inflection points., Results: Overall, 2,186 patients after robotic pancreatoduodenectomy were included. The feasibility learning curve was reached after 30-45 robotic pancreatoduodenectomy procedures and the proficiency learning curve after 90 robotic pancreatoduodenectomy procedures. These inflection points created 3 phases, which were associated with major morbidity (24.7%, 23.4%, and 12.3%, P < .001) but not 30-day mortality (2.1%, 2.0%, and 1.5%, P = .670). Other outcomes mostly continued to improve, including median operative time 432, 390, and 300 minutes (P < .0001), conversion 6.0%, 4.7%, and 2.7% (P = .002), bile leakage 7.2%, 4.1%, and 2.4% (P < .001), postpancreatectomy hemorrhage 6.5%, 6.1%, and 1.8% (n = 21) but not R0 resection (pancreatic ductal adenocarcinoma only) 78.5%, 73.9%, and 82.8% (P = .35), and 90-day mortality rate 3.1%, 3.5%, and 2.1% (P = .191). Centers performing >20 robotic pancreatoduodenectomies annually had lower rates of conversion, reoperation, and shorter median operative time as compared with centers performing 10-20 robotic pancreatoduodenectomies annually., Conclusion: This international multicenter study demonstrates that most outcomes of robotic pancreatoduodenectomy continued to improve during 3 learning curve phases without a negative effect on 90-day mortality. Randomized studies are needed in high-volume centers that have surpassed the first learning curves, to compare these outcomes with the open approach., (Copyright © 2024. Published by Elsevier Inc.)

Background: Robot-assisted pancreaticoduodenectomy (R-PD) helps further improve the safety and efficacy of minimally invasive pancreaticoduodenectomy. However, it faces challenges such as high costs and limitations in availability at different centers, making it difficult for patients to access. In this study, we evaluate the initial experience of Artisential®-assisted PD (A-PD) and compare its perioperative outcomes with R-PD, discussing the clinical applicability of A-PD., Methods: This study reviewed cases of R-PD and A-PD conducted between 2022 and 2023. A total of 34 patients underwent R-PD, while 26 patients underwent A-PD. Statistical analysis was conducted based on factors related to the patient's surgical procedure and postoperative prognostic indicators., Results: There were no significant differences observed between the two groups in terms of surgical factors. There were also no differences in the occurrence of postoperative complications. However, there was a significant difference in the length of hospital stay, with the Artisential® group having an average of 11.50 ± 5.54 days and the Robot group having 15.06 ± 5.34 days (p = 0.001)., Conclusions: R-PD and A-PD showed no differences in procedures or outcomes. Using a multi-articulated device is beneficial where robot use is challenging., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Pancreaticoduodenectomy with vascular reconstruction is rarely performed in children. We present a 3-year-old male with stage IV hepatoblastoma and pre-treatment extent of disease (PRETEXT) stage III with tumor into the portal vein and superior mesenteric vein (SMV), and with brain and lung metastases status post chemotherapy and stereotactic radiosurgery to left frontal brain lesion. He then underwent deceased donor liver transplant with Roux-en-Y hepaticojejunostomy complicated by two recurrences to bilateral lungs treated with wedge resections. His course lastly involved a third hepatoblastoma recurrence to the SMV that was managed with pylorus-preserving pancreaticoduodenectomy with SMV resection and reconstruction., (© 2024 Wiley Periodicals LLC.)

Introduction: A positive surgical margin (R1 resection) is a relevant risk factor for local recurrence in patients with pancreatic ductal adenocarcinoma of the pancreas (PDAC). An intraoperative liquid biopsy (ILB) based on tumor cell mobilization could help to detect R1 resection intraoperatively., Objective: To evaluate the potential role of the intraoperative circulating tumor cells (CTCs) and cluster mobilization on the R0/R1 detection., Methods: Sixty-three patients with resectable PDAC of the head of the pancreas were prospective enrolled under the CETUPANC trial. Open pancreaticoduodenectomy (PD) was done in all patients. Intraoperative CTCs and clusters were determined during PD., Results: The overall rate of R1 resection was 34.9% (22/63 patients). Multivariate analysis showed that factors associated with R1 resection (AUC=0.920) were the presence of undifferentiated G3 tumor (P=0.017), microscopic vascular invasion (P=0.016), and the intraoperative increase of both free CTCs and clusters in portal vein determination from the beginning to the end of the surgery (P=0.002 and P=0.005, respectively). A specific logistic regression model, including delta end to baseline CTCs and cluster mobilization to achieve a combined cut-off to detect R1 detection was calculated (AUC=0.799). The obtained R1-index based on ILB had 84% of sensitivity and 68% of specificity to detect R1 resection., Conclusions: The ILB based on the intraoperative mobilization of CTCs and clusters from the beginning to the end of the PD was a predictive factor to detect R1 resection in patients with PDAC., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: This study compared the incidence of postoperative pancreatic fistula (POPF) between standard invagination pancreaticojejunostomy (PJ) and an improved PJ technique after pancreaticoduodenectomy and evaluated the clinical utility of the improved PJ procedure., Methods: Clinical and postoperative data of 363 patients who underwent pancreaticoduodenectomy at the First Affiliated Hospital of Soochow University from February 2018 to October 2021 were analyzed retrospectively. In our cohort, 155 patients underwent the improved PJ technique (group A), and 208 underwent standard invagination PJ (group B). Data on demographic characteristics, pathological nature, intraoperative factors, and postoperative complications, including POPF, were collected and analyzed., Results: There were no significant between-group differences in demographic characteristics (p > 0.05). The improved PJ technique was associated with a significantly lower incidence of clinically relevant POPF (CR-POPF) in the total cohort (11.6 % vs. 26.4 %, p < 0.001) and in the subgroup with high fistula risk scores (16.0 % vs. 38.6 %, p < 0.001)., Conclusion: The improved invagination PJ technique reduces the incidence of CR-POPF and improves prognosis., Competing Interests: Declaration of competing interest Authors certify that there is no conflict of interest related to the manuscript., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Pancreaticoduodenectomy (PD) is the standard surgery to treat tumors and other conditions affecting the head of the pancreas. PD involves the division of the gastroduodenal artery (GDA) and its branches, to allow for complete dissection of lymph nodes. However, PD in patients with prior esophageal resection presents challenges due to altered anatomy and risks compromising gastric tube vascularization. GDA preservation becomes crucial to avoid ischemia, although this may pose oncological risks by potentially leaving behind regional lymph nodes. This article reviews European surgical center experiences and techniques for PD in patients with prior esophageal surgery, focusing on short-term outcomes., Methods: We have collected all the experiences carried out in European surgical centers and evaluated the techniques applied for PD in patients who had prior esophageal surgery while analyzing short-term outcomes., Results: Eight patients from 5 European centers were identified. Six patients were diagnosed with pancreatic adenocarcinoma, including one borderline case. Intraoperatively, the gastroduodenal artery (GDA) was preserved in all cases, with portal vein reconstruction required in only one instance due to tumor invasion. No ischemia or venous congestion of the gastric tube was observed during the surgical procedure. Post-operative complications that occurred included POPF type C in 1 (12.5 %), PPH type C in 1 (12.5 %). The median number of harvested lymph nodes was 21 [14-24]. with a median of 1.5 positive lymph nodes. R1 resection was present in 62.5 % of cases., Conclusion: Performing pancreaticoduodenectomy subsequent to Ivor Lewis esophagectomy is a technical challenge, but seems feasiable and safe in selected patients. GDA-preserving pancreaticoduodenectomy emerges as a valuable and time-efficient variation of the conventional procedure, it can be considered oncologically appropriate, but studies confirming its long-term impact on radicality are still needed., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: The aim of this study is to assess the impact of obesity on the perioperative outcomes in robotic pancreaticoduodenectomy (RPD), rarely documented., Methods: A total of 886 patients undergoing RPD or open pancreaticoduodenectomy (OPD) were enroled. These patients were categorised into the obese RPD, non-obese RPD and obese OPD groups., Results: Operation time was longer in obese RPD compared with non-obese RPD and obese OPD (median: 9.5 vs. 7.5 and 8.0 h). Blood loss was lower in both RPD groups than in the obese OPD group (median: 200 and 120 vs. 500 c.c.). Surgical mortality and morbidity were comparable between these three groups. Delayed gastric emptying (DGE) occurred less frequently in both RPD groups than obese OPD (7.5% and 4.4% vs. 19.1%)., Conclusions: Obesity does not exert a negative impact on the perioperative outcomes in RPD, except for longer operation times. RPD has emerged as a safe and viable surgical approach for obese patients., (© 2024 The Author(s). The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons Ltd.)

Background: Minimally invasive pancreatoduodenectomy (MIPD) has emerged as an alternative to open pancreatoduodenectomy (OPD). However, the extent of variation in the use and outcomes of MIPD in relation to OPD among countries is unclear as international studies using registry data are lacking. This study aimed to investigate the use, patient selection, and outcomes of MIPD and OPD in four transatlantic audits for pancreatic surgery., Methods: A post hoc comparative analysis including consecutive patients after MIPD and OPD from four nationwide and multicenter pancreatic surgery audits from North America, Germany, the Netherlands, and Sweden (2014-2020). Patient factors related to MIPD were identified using multivariable logistic regression. Outcome analyses excluded the Swedish audit because < 100 MIPD were performed during the studied period., Results: Overall, 44,076 patients who underwent pancreatoduodenectomy were included (29,107 North America, 7586 Germany, 4970 the Netherlands, and 2413 Sweden), including 3328 MIPD procedures (8%). The use of MIPD varied widely among countries (absolute largest difference [ALD] 17%, p < 0.001): 7% North America, 4% Germany, 17% the Netherlands, and 0.1% Sweden. Over time, the use of MIPD increased in North America and the Netherlands (p < 0.001), mostly driven by robotic MIPD, but not in Germany (p = 0.297). Patient factors predicting the use of MIPD included country, later year of operation, better performance status, high POPF-risk score, no vascular resection, and non-malignant indication. Conversion rates were higher in laparoscopic MIPD (range 28-45%), compared to robotic MIPD (range 9-37%). In-hospital/30-day mortality differed among North America, Germany, and the Netherlands; MIPD (2%, 7%, 4%; ALD 5%, p < 0.001) and OPD (2%, 5%, 3%; ALD 3%, p < 0.001), similar to major morbidity; MIPD (25%, 42%, 38%, ALD 17%, p < 0.001) and OPD (25%, 31%, 30%, ALD 6%, p < 0.001), respectively., Conclusions: Considerable differences were found in the use and outcome, including conversion and mortality rates, of MIPD and OPD among four transatlantic audits for pancreatic surgery. Our findings highlight the need for international collaboration to optimize treatment standards and patient outcome., Competing Interests: Declarations. Disclosures: Nine de Graaf, Marc G. Besselink and Mohammad Abu Hilal received funding from Intuitive Surgical® for the investigator-initiated DIPLOMA-2 randomized trial on minimally invasive versus open pancreatoduodenectomy; Marc G. Besselink received funding from Amsterdam UMC for studies on safe implementation of robotic pancreatic surgery; funding from the Dutch Digestive Foundation (‘Maag Lever Darm Stichting’), for investigator-initiated studies on minimally invasive pancreatic surgery (Agreement ID: I 16-05); from Intuitive Surgical® for the investigator-initiated LAELAPS-3 training program for robotic PD in the Netherlands for which training suturing material was provided by ETHICON, Johnson & Johnson; from Intuitive® for the investigator-initiated LEARNBOT training program for robotic PD in Europe; Simone Augustinus, Ulrich Wellner, Karin Johansen, Bodil Andersson, Joal D. Beane, Bergthor Björnsson, Olivier R. Busch, Catherine H. Davis, Michael Ghadimi, Elizabeth M. Gleeson, Bas Groot Koerkamp, Melissa E. Hogg, Hjalmar C. van Santvoort, Bobby Tingstedt, Waldemar Uhl, Jens Werner, Caroline Williamsson, Herbert J. Zeh, Amer H. Zureikat, Henry A. Pitt, and Tobias Keck have no conflicts of interest or financial ties to disclose., (© 2024. The Author(s).)

Background: The superior mesenteric artery (SMA)-first approach for pancreatic cancer (PC) is common surgical technique in pancreaticoduodenectomy. To date, few studies have reported SMA-first approach in robot-assisted pancreaticoduodenectomy (RPD). Herein, we present the anterior SMA-first approach for PC during RPD., Patient and Method: A 75-year-old man with resectable PC underwent RPD after neoadjuvant chemotherapy. As pancreatic head tumor contacted with the superior mesenteric vein (SMV), the anterior SMA approach was applied. After the mesenteric Kocher maneuver, the jejunum was divided and the left side of the SMA was dissected. Subsequently, the anterior plane of the SMA was dissected. Following the division of branches from the mesenteric vessels, the SMA was taped, and the circumferential dissection around the SMA was performed to detach the pancreatic neck from the SMA completely. Finally, the dissection between the SMV and the tumor was performed under vascular control to remove the specimen., Conclusions: The anterior SMA-first approach can be optional in patients with PC undergoing RPD. This unique approach allows for the circumferential dissection around the SMA during RPD., (© 2024. The Author(s).)

Background: To determine whether ligamentum teres hepatis and falciform ligament, wrapped around the gastroduodenal artery (GDA) and reinforced the posterior wall in pancreatojejunostomy (PJ), protects the GDA stump and other skeletal blood vessels from erosive hemorrhage and reduces the incidence of clinically relevant post-operative pancreatic fistula (CR-POPF) and post-operative complications after laparoscopic pancreaticoduodenectomy (LPD)., Methods: We reviewed patients undergone LPD between January 2019 and June 2023. Patients were divided into two groups according to whether the ligamentous flap had been used to wrap the GDA stump (Group A) or to reinforce the posterior wall in PJ, together with the GDA wrapping procedure (Group B). Peri-operative data were reviewed to determine the effectiveness of this approach in preventing CR-POPF, post-pancreatectomy hemorrhage (PPH), and other complications., Results: We enrolled 272 patients (Group A, 154 patients; Group B, 118 patients). Group B patients had significantly fewer ≥ Grade II Clavien-Dindo classification morbidities and CR-POPFs (P < 0.05), and lower length of hospital stay (LOS) and abdominal drainage tube insertion times. Risk factor analysis indicated that main pancreatic duct dilation, the PJ reinforcement procedure, and soft pancreatic tissue were associated with ≥Grade II Clavien-Dindo morbidities and CR-POPF complications., Conclusions: The ligamentous flap application in LPD provided shelter to GDA stump and other skeletal blood vessels under PJ from erosive digestive juices, reinforced the posterior wall in PJ, reduced the incidence of CR-POPF and ≥Grade II Clavien-Dindo classification morbidities. This simple procedure is effective for improving surgical safety of LPD., Competing Interests: Declaration of competing interest None of the authors is involved in an activity that has a conflict of interest with the topic and contents of this publication., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Pancreaticoduodenectomy (PD) is a complex procedure involving the dissection of the superior mesenteric artery and vein. However, a safe and standardized technique for dissecting the jejunal veins (JVs) in the mesojejunum during PD remains elusive., Methods: We retrospectively analyzed 198 patients who underwent open PD with mesojejunum dissection using an anterior artery-first approach and evaluated anatomical variations in the first JV trunk (FJVT) and its tributaries. This study introduces the concept of a "dangerous crossover vein" (DCV) to describe tributaries that cross the transection line of the mesojejunum. Surgical techniques and perioperative outcomes were assessed., Results: The FJVT drained the territory supplied by the first to second jejunal arteries in 144 patients (75%) and the first to third or more in 50 patients (25%). The FJVT was preserved in 100 patients (50.5%) and sacrificed in 98 (49.5%). Dangerous crossover veins were encountered in 117 patients (59%) and safely managed with standardized mesojejunal dissection. There were no significant differences in blood loss or operative time between patients with or without DCVs., Conclusions: Understanding the anatomy of JVs and the concept of DCVs is critical for safe mesojejunal dissection during PD. Our approach facilitates secure dissection of JVs regardless of their anatomical variations., Competing Interests: Disclosures: The authors declare no conflicts of interest., (© 2024. Society of Surgical Oncology.)

Surgical management of pancreas cancer is complex, including the timing of surgery, surgical approach, intraoperative techniques, and postoperative management, which are reviewed in detail in this manuscript. Ultimately, referral to a high-volume pancreatic surgeon or pancreatic surgery center is critical to ensuring appropriate short-term and long-term outcomes., Competing Interests: Disclosures We do not have any commercial or financial conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To develop a universally accepted complexity and experience grading system to guide the safe implementation of robotic and laparoscopic minimally invasive pancreatoduodenectomy (MIPD)., Background: Despite the perceived advantages of MIPD, its global adoption has been slow due to the inherent complexity of the procedure and challenges to acquiring surgical experience. Its wider adoption must be undertaken with an emphasis on appropriate patient selection according to adequate surgeon and center experience., Methods: The International Study Group for Pancreatic Surgery (ISGPS) developed a complexity and experience grading system to guide patient selection for MIPD based on an evidence-based review and a series of discussions., Results: The ISGPS complexity and experience grading system for MIPD is subclassified into patient-related risk factors and provider experience-related variables. The patient-related risk factors include anatomic (main pancreatic and common bile duct diameters), tumor-specific (vascular contact), and conditional (obesity and previous complicated upper abdominal surgery/disease) factors, all incorporated in an A-B-C classification, graded as no, a single, and multiple risk factors. The surgeon and center experience-related variables include surgeon total MIPD experience (cutoffs 40 and 80) and center annual MIPD volume (cutoffs 10 and 30), all also incorporated in an A-B-C classification., Conclusions: This ISGPS complexity and experience grading system for robotic and laparoscopic MIPD may enable surgeons to optimally select patients after duly considering specific risk factors known to influence the complexity of the procedure. This grading system will likely allow for a thoughtful and stepwise implementation of MIPD and facilitate a fair comparison of outcomes between centers and countries., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)