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Background: There is an ongoing debate about the most appropriate method for reconstructing the pancreas after a pancreaticoduodenectomy (PD). This study assessed the impact of pancreaticogastrostomy (PG) with an external pancreatic stent on postoperative outcomes following PD in high-risk patients. Patients and methods: This study involves a propensity score-matched analysis of high-risk patients who underwent PD with PG reconstruction. The primary outcome measure was the occurrence of Postoperative Pancreatic Fistula (POPF). Secondary outcomes included operative time, intraoperative blood loss, length of hospital stay, re-exploration rate, as well as postoperative morbidity and mortality rates. Results: The study included 78 patients; 26 patients underwent PD with Pancreatogastrostomy (PG) and an external pancreatic stent, while 52 underwent PG without a pancreatic stent. Blood loss and operative time did not significantly differ between the two groups. The overall postoperative morbidity was higher in the group without a stent than in the stented group (34.6% vs. 15.4%, P = 0.06). No patient in the pancreatic stent group developed a clinically relevant POPF; however, in the non-stented group of PG, 17.3% developed POPF. There were no cases of hospital mortality in the stented group. However, in the non-stented group, two hospital mortality happened (one case was due to the systemic inflammatory response syndrome (SIRS) secondary to POPF grade C, and the other was due to pulmonary embolism. Conclusion: PG with an external pancreatic stent results in fewer clinically relevant pancreatic fistulas, a decrease in postoperative morbidities, and a non-existent mortality rate in high-risk patients. [ABSTRACT FROM AUTHOR]

Background: The recent International Study Group for Pancreatic Surgery (ISGPS) risk classification for postoperative pancreatic fistula (grade B/C) was developed based on data from open and mixed minimally invasive pancreatoduodenectomy. The ISGPS risk classification model has not been validated specifically for POPF after robotic pancreatoduodenectomy (RPD). Methods: We calculated the rate of POPF (ISGPS 2016 definition, grade B/C) by analyzing consecutive patients after RPD by surgeons after their learning curves (80 RPDs per surgeon). The validation of the ISGPS 4-tier and the simplified 3-tier risk classification was conducted using the area under the receiver operating curve (AUC). Results: From 2019 to 2023, 187 patients after RPD were included. Neither the ISGPS 4-tier nor the simplified 3-tier classification model showed robust discrimination (AUC: 0.696 and 0.685, respectively). Moreover, both risk classifications failed to differentiate the rates of POPF and major complications among subgroups. Multivariate analysis suggested that soft pancreatic texture and pancreatic duct ≤ 2 mm were independent risk factors for POPF after RPD. After adjusting the duct size's cutoff from 3 to 2 mm, the revised 4-tier "2 mm" classification model showed no significant difference between risk categories B and C (6.7% vs. 9.4%, P = 0.063). The revised 3-tier "2 mm" classification model stratified patients into A (n = 54), B (n = 68), and C (n = 65) groups, with corresponding POPF rates of 0.0%, 8.8%, and 23.1% (P < 0.001), and major complication rates of 5.6, 14.7, and 24.6% (P = 0.014), respectively. Compared to the simplified 3-tier classification model, the revised 3-tier "2 mm" classification model showed improved discrimination (AUC: 0.753 vs. 0.685, P = 0.034) and clinical utility. Conclusions: The current ISGPS 4-tier and the simplified 3-tier classification models lacked sufficient discrimination in patients after RPD. We propose a revised 3-tier "2 mm" risk classification model for RPD with a robust discrimination, which requires further international validation with prospectively obtained data. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. 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. 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%). 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. [ABSTRACT FROM AUTHOR]

Post-pancreatectomy hemorrhage (PPH) is a fatal complication of pancreatoduodenectomy. When complicated by a pancreatic fistula, pancreatic juice contacting the artery may form a pseudoaneurysm and cause arterial bleeding. We used Hem-o-lok® clips to prevent damage to the outer wall of the gastroduodenal artery (GDA). This study evaluated the usefulness of using Hem-o-lok® clips to ligate the GDA stump to prevent PPH. Overall, 468 patients who underwent PD at our hospital were included. Before July 2020, we ligated the GDA stump using the knot-tying method, which involves double ligation. After July 2020, the GDA stump was double clipped using a 10-mm Hem-o-lok® clip to the residual side without tension on the GDA. Propensity score matching was used to compare cases of pancreatic fistulas that underwent clipping vs. knot-tying. Propensity score matching resulted in 37 patients in each group. PPH occurred in 12 (16.4%) and 4 (6.9%) patients in the knot-tying and clipping groups, respectively. PPH from the GDA stump occurred in eight (11.0%) and one (1.7%) patient in the knot tying and clipping groups, respectively (P = 0.044). Hem-o-lok® clips are safe to apply on the GDA stump during pancreatoduodenectomy to prevent PPH. [ABSTRACT FROM AUTHOR]

An increasing number of elderly patients are being diagnosed with pancreatic cancer, with increasing need to consider pancreatic surgery. This study aims to provide an updated systematic review and meta-analysis to evaluate the outcomes following pancreaticoduodenectomy in octogenarians. A systematic review and meta-analysis was performed via a search of Medline, PubMed and Cochrane databases. Studies comparing outcomes of patients >80 years to younger patients undergoing PD were included. 26 studies were included. This included 22481 patients, with 20134 (89.6%) aged <80 years old, and 2347 (10.4%) octogenarians. Octogenarians were associated with higher rates of mortality (OR 2.37 (95%CI 1.91-2.94, p < 0.00001)), all-cause morbidity (OR 1.60 (95%CI 1.30-1.96), p<0.00001) and re-operation (OR 1.41 (95%CI 1.13-1.75), p = 0.002). Octogenarians had a two-fold risk of cardiac complications and respiratory complications (OR 2.13 (95%CI 1.67-2.73), p < 0.00001), (OR 2.38 (95%CI 1.72-3.27), p < 0.0001). There was no difference in postoperative pancreatic fistula, post-pancreatectomy hemorrhage or delayed gastric emptying. Younger patients were more likely to return to adjuvant therapy (OR 0.20 (95%CI 0.12-0.34), p < 0.00001). Octogenerians are associated with higher mortality rate, postoperative complications, and reduced likelihood to undergo adjuvant therapy. Careful preoperative assessment and selection of elderly patients for consideration of pancreatic surgery is essential. [ABSTRACT FROM AUTHOR]

The article discusses a new technique for pancreaticojejunostomy after pancreaticoduodenectomy to reduce the risk of postoperative pancreatic fistula. The study included 141 patients and found that the single-layer interrupted spoke wheel suture technique showed promising outcomes. Factors like soft pancreas, narrow main pancreatic duct, and high BMI did not show associations with clinically relevant postoperative pancreatic fistula. The technique described in the article may offer a safer option for specific situations, although it does not claim superiority over other pancreaticoenteric anastomosis techniques. [Extracted from the article]

Gut microbiota status after pancreaticoduodenectomy (PD) is unclear, and postoperative fatty liver is an important complication after PD. This study evaluated the relationship between postoperative fatty liver and gut microbiota after PD. Fecal samples were collected from patients who had undergone PD and remained stable after 6 months of follow-up. A comprehensive bacterial analysis using 16S rRNA gene amplicon sequencing was performed. The results were compared with those of 85 healthy volunteers. The association between perioperative factors, gut microbiota, and development of fatty liver was investigated. Twenty-four patients after PD, including 10 in the fatty liver (FL) group and 14 in the normal liver (NL) group were investigated. The β-diversity of the gut microbiota was significantly different between the healthy volunteers and patients after PD, with more Escherichia coli and Streptococcus gallolyticus and less Bifidobacterium catenulatum and Faecalibacterium prausnitzii in the patients with PD. Lactobacillus gasseri was significantly less abundant in the FL group than in the healthy volunteers, although this change was not observed in the NL group. The gut microbiota of patients after PD was in dysbiosis at postoperative ≥6 months. Development of fatty liver might be associated with significant differences in gut microbiota. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The clinical diagnosis and treatment of dilation of the cholangiopancreatic duct in patients with ambiguous ampullary disease, termed unexplained dilation of the cholangiopancreatic duct (UDCD), is commonly difficult. This study aimed to evaluate the applicability of transduodenal ampullectomy (TDA) for the diagnosis and treatment of UDCD. Methods: We first proposed a surgical exploration procedure based on the TDA and applied it in a representative UDCD patient. We retrospectively analyzed the pathological diagnosis and prognosis of 14 patients at our hospital and 189 patients reported in existing studies who were treated with TDA between January 2010 and December 2022. Results: TDA can be used to radically explore the ampullary region and harvest adequate pathological tissue, which is helpful for identifying the cause of UDCD. The diagnostic rate of intraoperative frozen pathology was greater than that of preoperative endoscopic biopsy (78.41% vs. 65.94%, P = 0.044). The postoperative complication rate was 27.07%, with a mortality rate of 0.00%. The 5-year survival rate was 68.31% in patients with adenocarcinoma, 85.99% in patients with adenoma with HGD/pTis, and 100% in patients with benign lesions, and these had a statistically significant difference (P = 0.021). Conclusions: TDA-based surgical exploration can be used as a safe and effective transitional procedure in the treatment of UDCD. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions To evaluate recent minimally invasive pancreatectomy (MIP) trends for neoplastic disease and compare perioperative outcomes.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.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.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). [ABSTRACT FROM AUTHOR]

Organ/space surgical site infection (SSI) are common after pancreaticoduodenectomy (PD). There is limited research on the clinical impact of intraoperative lavage fluid contamination in patients undergoing PD. One hundred five patients who underwent PD between August 2022 and July 2023 were retrospectively enrolled. The intraoperative bile and peritoneal lavage were collected for bacterial culture. Postoperative drainage bacterial cultures were performed every 2–3 days thereafter until drains were all removed. The bacteria isolated from intraoperative lavage fluid, intraoperative bile, and postoperative drainage fluid were examined in detail. The risk factors associated with positive intraoperative lavage fluid culture were analyzed through both univariate and multivariate analyses. Organ/space SSI occurred in 59(56.2%) of the 105 patients. The positivity rates of cultures in intraoperative lavage fluid, intraoperative bile, and postoperative drainage fluid were found to be 41.0%, 67.6%, and 84.8%, respectively. Patients with positive intraoperative lavage fluid culture had a significantly higher occurrence of organ/space SSI compared to the negative group (69.0% vs. 29.4%, P < 0.001). Preoperative biliary drainage (PBD) was identified as the only independent risk factor for the contamination of intraoperative lavage fluid (OR = 7.687, 95% CI: 2.164–27.300, P = 0.002). K. pneumoniae was the most common isolates both in the intraoperative lavage fluid and postoperative drainage fluid. Intraoperative lavage fluid contamination closely correlated with organ/space SSI after PD. Meanwhile, PBD was the only risk factor for the contamination of intraoperative lavage fluid. [ABSTRACT FROM AUTHOR]

Background: The feasibility and safety of laparoscopic pancreaticoduodenectomy (LPD) in overweight patients is still controversial. This study was designed to analyze the impact of overweight on surgical outcomes in patients undergoing LPD. Methods: Data from patients who underwent LPD between January 2018 and July 2022 were analyzed retrospectively. A 1:1 propensity score-matching (PSM) analysis was performed to minimize bias between groups. Results: A total of 432 patients were enrolled, with a normal weight group (n = 241) and an overweight group (n = 191). After matching, 144 patients were enrolled in each group. The results showed that the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) and delayed gastric emptying (DGE) was significantly higher in the overweight group compared to the normal weight group (P = 0.036). However, there were no significant differences in perioperative mortality (1.4% vs. 2.1%, P = 0.652) and long-term survival outcomes between malignancy patients with different body mass index (BMI) before and after PSM (all P > 0.05). Conclusions: It is safe and feasible for overweight patients to undergo LPD with mortality and long-term survival outcomes comparable to the normal weight group. High-quality prospective randomized controlled trials are still needed. [ABSTRACT FROM AUTHOR]

Background: Open pancreaticoduodenectomy (OPD) is an essential surgical procedure for expert hepato-biliary-pancreatic (HBP) surgeons. However, there is no standard for how many surgeries must be performed by a surgeon in training before they are considered to have enough experience to ensure surgical safety. Methods: Cumulative Sum (CUSUM) analysis was performed using the surgical data of OPDs performed during the training period of board-certified expert surgeons of the Japanese Society of Hepato-Biliary-Pancreatic Surgery. Results: Fourteen HBP surgeons participated in this study and performed 334 OPDs during their training period. The median (interquartile range) values for operative time, blood loss, and length of hospital stay were 455 (397–519) minutes, 450 (234–-716) ml, and 28 (21–38) days, respectively. CUSUM analysis showed inflection points at 20 surgeries performed for operative time. After 20 procedures, operative time was significantly shorter (461 min vs. 425 min, p = 0.021) and blood loss was significantly lower (470 ml vs. 340 ml, p = 0.038). No significant differences between within 20 and after 21 procedures were found in the complication rate (53% vs. 48%, p = 0.424) and rate of in-hospital deaths (1.5% vs.1.4%. p = 0.945). Up to 20 surgeries, PDAC and another malignant tumor had longer operative time than benign/low malignant diseases (486 min vs. 472 min vs. 429 min, p < 0.001), and higher blood loss (500 ml vs. 502 ml vs. 355 ml, p < 0.001). Mortality rate was higher at PDAC cases (5% vs. 0% vs. 0%, p = 0.01). After the 21 procedures, these outcomes were improved and no differences in by primary disease were observed. Multivariable analysis showed that within 20 surgeries were independent risk factors of longer operative time (HR2.6, p = 0.013) and higher blood loss (HR2.0, p = 0.049). Conclusions: To stabilize the surgical outcome of OPD for malignant disease, at least 20 surgeries should be performed at a certified institution during surgeon training. Trial registration: Clinical trial number: Not applicable. [ABSTRACT FROM AUTHOR]

Background/Objectives: Autoimmune pancreatitis (AIP) is a diagnosis-challenging disease that often mimics pancreatic malignancy. Pancreatic resection is considered to be a curative treatment for pancreatic ductal adenocarcinoma (PDAC). This meta-analysis aims to study the incidence of AIP in patients who have undergone pancreatic resection for clinical manifestation of cancer. Methods: A comprehensive search was conducted in three databases, PubMed, Embase and the Cochrane Library, using the terms 'autoimmune pancreatitis' and 'pancreatic resection' and supplemented by manual checks of reference lists in all retrieved articles. Results: Ten articles were included in the final analysis. 8917 pancreatic resections were performed because of a clinical suspicion of pancreatic cancer. AIP accounted for 140 cases (1.6%). Type 1 AIP comprised the majority of cases, representing 94% (132 cases), while type 2 AIP made up the remaining 6% (eight cases) after further classification. AIP accounted for almost 26% of all cases of benign diseases involving unnecessary surgery and was overrepresented in males in 70% of cases compared to 30% in females. The mean age for AIP patients was 59 years. Serum CA 19 − 9 levels were elevated in 23 out of 47 (49%) AIP patients, where higher levels were detected more frequently in patients with type 1 AIP (51%, 22 out of 43) than in those with type 2 AIP (25%, 1 out of 4). The sensitivity of IgG4 levels in type 1 AIP was low (43%, 21/49 patients). Conclusion: Even with modern diagnostic methods, distinguishing between AIP and PDAC can still be challenging, thus potentially resulting in unnecessary surgical procedures in some cases. Serum CA 19 − 9 levels are not useful in distinguishing between AIP and PDAC. Work must thus be done to improve diagnostic methods and avoid unnecessary complicated surgery. [ABSTRACT FROM AUTHOR]

Background: This systematic review and meta-analysis aimed to evaluate the impact of perioperative immunonutrition on postoperative outcomes in patients undergoing pancreaticoduodenectomy (PD). Methods: Conducted a comprehensive search in PubMed, Embase, Cochrane Library, Medline, and Web of Science databases to identify all randomized controlled trials (RCTs) on the topic of immunonutrition and PD. Subsequently screened literature, extracted data, and assessed the risk of bias in the included studies, and finally conducted a meta-analysis using RevMan 5.3 software. Results: The analysis included a total of 10 RCTs with 574 patients, among whom 288 were in the immunonutrition group and 283 in the control group. The meta-analysis revealed a significantly lower incidence of postoperative infection-related complications (OR = 0.45; 95% CI: 0.27–0.74; P = 0.002) and severe postoperative complications (OR = 0.61; 95% CI: 0.38–0.98; P = 0.04) in the immunonutrition group compared to the control group. Additionally, patients in the immunonutrition group had a significantly shorter length of hospital stay (MD= -1.87; 95%CI -3.29 - -0.44; P = 0.01). However, the analysis revealed no statistically significant difference in the overall complication rate between the two groups (P = 0.67). Furthermore, the incidence of specific complications and perioperative mortality rates also did not demonstrate any statistically significant differences (all P > 0.05). Conclusions: Perioperative immunonutrition in PD patients can reduce postoperative infection-related complications, but more high-quality RCTs are needed for further validation. [ABSTRACT FROM AUTHOR]

Background and Aim Methods Results Conclusion Early predictors of morbidity after pancreaticoduodenectomy (PD) can guide tailored postoperative management. Preoperative inflammatory data in patients who underwent PD remained poorly studied in investigating the clinical significance of predicting postpancreatectomy acute pancreatitis (PPAP) and PPAP‐associated postoperative pancreatic fistula (POPF).The clinical data of 467 patients receiving PD between January 2020 and December 2022 were retrospectively reviewed. Preoperative inflammatory data were stratified according to PPAP, and independent risk factors were analyzed. Multivariate logistic regression and subgroup analyses were conducted to compare risk factors of PPAP‐associated POPF and non‐PPAP‐associated POPF.PPAP occurred in 17.6% of patients. The incidence of other complications increased following PPAP. Among the preoperative inflammatory factors, only interleukin‐6 (IL‐6) increased (P < 0.001), leading to a higher incidence of PPAP and POPF (P < 0.001; P = 0.002). The area under the curve of IL‐6 in predicting PPAP was 0.71 (0.65–0.77; P < 0.001). Abnormal preoperative IL‐6 levels (odds ratio [OR]: 5.01; P < 0.001), soft pancreatic texture (OR: 2.15; P = 0.007), and pathology (OR: 2.03; P = 0.012) were independent risk factors for PPAP. The subgroup analysis showed that increased IL‐6 (OR: 1.01; P = 0.006) and soft pancreatic texture (OR: 2.05; P = 0.033) resulted in a higher risk of PPAP‐associated POPF, while increased IL‐8 (OR: 1.01; P = 0.007), older age (OR: 1.05; P = 0.008), and higher body mass index (OR: 1.12; P = 0.021) correlated with non‐PPAP‐associated POPF.PPAP is common after PD; a high preoperative IL‐6 level can predict its occurrence, in addition to associated POPF, which could be due to a preoperative proinflammatory status. [ABSTRACT FROM AUTHOR]

Background: The current gold standard for postoperative analgesia following a pancreaticoduodenectomy (PD) is a thoracic epidural analgesia (TEA). Spinal analgesia with continuous wound infusion (CWI) of local anaesthetic is an emerging alternative modality. This non-inferiority study aimed to compare CWI with spinal analgesia to TEA and assess its impact on clinical outcomes. Methods: A retrospective observational analysis of patients undergoing open pancreatoduodenectomy through a midline laparotomy. A total of 74 patients were included in the study forming two groups: CWI (n = 33) and TEA (n = 41). Results: TEA resulted in lower median pain scores at rest (p = 0.002) and with coughing (p = 0.005) on postoperative day 2. CWI was non-inferior to TEA for all other pain outcomes measures from days 0–5. Patients in the CWI group had a shorter time to first bowel motion (p = 0.001), commencement of a liquid diet (p = 0.04), earlier removal of nasogastric tube (p = 0.005), abdominal drain (p = 0.003) and indwelling catheter (p < 0.001). Analgesic failure and postoperative nausea and vomiting were also less frequent (p = 0.001 and p < 0.001 respectively). Conclusion: Local CWI with spinal analgesia was non-inferior to TEA for pain management in open pancreaticoduodenectomy. CWI demonstrated advantages in measures associated with enhanced recovery after surgery programs without disadvantages in terms of analgesia requirements. [ABSTRACT FROM AUTHOR]

Background: Although pancreaticoduodenectomy (PD) for pancreatic or periampullary cancer is the gold standard treatment regardless of patient age, patients aged 80 years or older have poor postoperative short-term outcomes because of their poor functional status and many medical comorbidities. Postoperative rehabilitation in octogenarians could improve postoperative outcomes; however, its effect remains unclear. Methods: This retrospective study included patients who underwent PD at two institutions between January 2019 and December 2022. All patients were managed using the enhanced recovery after surgery (ERAS) protocol, and elderly patients or those with loss of muscle mass or frailty underwent additional perioperative rehabilitation. Postoperative short-term outcomes were compared between the octogenarians and non-octogenarians. Results: We reviewed 251 patients including 44 octogenarians (17.5%). Octogenarians had higher rates of comorbidity (78.9% vs. 55.1%, P = 0.049) and sarcopenia (31.8% vs. 16.4%, P = 0.018) and a more impaired nutritional status than non-octogenarians and received postoperative rehabilitation more frequently (86.4% vs. 44.0%, P < 0.001, respectively). Under the rehabilitation-enhanced ERAS protocol, the postoperative major complication rate (25.0% vs. 24.6%, P = 0.960), the length of hospital stay (LOS) (P = 0.435), and the length of functional recovery (LOFR) (P = 0.110) did not differ between the two groups. In the multivariate analysis, age ≥ 80 years was not determined as a risk factor for major complications. Conclusions: Despite the poor functional and nutritional status of octogenarians, their postoperative major complication rates, LOS, and LOFR after PD were comparable with those of non-octogenarians under the rehabilitation-enhanced ERAS protocol. [ABSTRACT FROM AUTHOR]

Purpose: This study evaluated the impact of renal function impairment on long-term survival outcomes and adjuvant therapy in patients with pancreatic cancer undergoing pancreaticoduodenectomy (PD). Methods: In this study, 264 patients who underwent PD for pancreatic head cancer between 2011 and 2021 were retrospectively analyzed. The patients were subsequently categorized into three groups according to the estimated glomerular filtration rate: normal group (> 90 mL/min/1.73 m2, n = 73), moderate group (45–90 mL/min/1.73 m2, n = 176), and severe group (< 45 mL/min/1.73 m2, n = 15). The primary outcomes evaluated were postoperative complications, overall survival (OS), and relapse-free survival (RFS). Additionally, the completion of adjuvant therapy and risk factors for adjuvant therapy discontinuation were analyzed. Results: The total proportion of patients with complications was significantly higher in the severe group (p = 0.008). The proportion of patients with severe complications (Clavien–Dindo classification ≥ IIIa) did not significantly differ between the chronic kidney disease (CKD) groups (p = 0.730). The proportion of patients in whom adjuvant therapy was completed was notably lower in the severe group (p = 0.011). Multiple logistic regression analysis revealed that CKD groups and hemoglobin levels ≤ 11.5 g/dL were independent predictors of adjuvant therapy completion failure (p = 0.016 and p = 0.016). There was no significant difference in the OS and RFS rates between the CKD groups (p = 0.499, p = 0.688). Conclusions: In patients with pancreatic cancer and CKD, performing PD safely may be feasible; however, adjuvant therapy completion is challenging. [ABSTRACT FROM AUTHOR]

Pancreatic schwannomas are exceedingly rare tumors arising from Schwann cells of the peripheral nerve sheath within the pancreas. Often asymptomatic or presenting with nonspecific symptoms, these tumors pose a diagnostic challenge due to their mimicry of other pancreatic neoplasms on imaging studies. Histologically, pancreatic schwannomas demonstrate spindle cell proliferation with a distinct Immunohistochemical profile, including positive staining for S-100 protein. Surgical resection remains the cornerstone of treatment, with excellent long-term prognosis following complete excision. Here, we present a case report of a pancreatic schwannoma in a woman presenting with a cystic pancreatic mass, underscoring the importance of considering this rare entity in the differential diagnosis of pancreatic lesions. [ABSTRACT FROM AUTHOR]

Background: The adoption of robotic pancreaticoduodenectomy (PD) has increased in recent years for the treatment of pancreatic head tumors and periampullary lesions. Some potential benefits seem to be demonstrated; however, obtaining specimens through this method can potentially compromise the diagnosis depending on the timing of the specimen retrieval, and the impact of longer perioperative time on ischemia and autolysis of the surgical specimen has not been analyzed. The aim of this study is to evaluate the histological changes associated with timing of specimen retrieval during robotic PD. Methods: A review of histopathology files was performed for all pancreatic specimens collected at our hospital from January 2022 to March 2024. Both warm ischemia time (WIT) and cold ischemia time (CIT) were collected. Histological features related to ischemic damage were evaluated in normal duodenal and pancreatic parenchyma as well as pancreatic tumor, and were graded as: absent, mild, moderate and severe. Univariate and multivariate analyses were performed to determine which variables were associated with moderate and severe ischemic changes. Results: Sixty surgical specimens were analyzed: 20 open PD, 17 robotic PD with cold ischemia, and 23 robotic PD. Median total WIT was 182 min (open PD 57 min vs. RPD 190 min vs. RPD-CI 198 min; p < 0.001). Median CIT was 760 min (740–835) in samples stored at 4ºC. Univariate analysis showed that longer intraoperative time, male gender and cold ischemia were associated with pancreatic tissue ischemic changes. In multivariate analysis, cold ischemia was the only independent factor associated with normal pancreatic tissue and tumor tissue moderate and severe ischemic changes. Conclusions: Prolonged ischemia time, especially in the case of cold storage, has a strong effect on the degradation of normal and tumor tissue without affecting pathological evaluation. Operative teams should aim to optimize both the duration and efficiency of the surgical procedure, ensuring minimal ischemic time. Simultaneously, pathology departments must be equipped to process pancreatic specimens promptly, with protocols in place to minimize the time between resection and analysis. [ABSTRACT FROM AUTHOR]

Objective: To systematically review the risk prediction models for postoperative pancreatic fistula （POPF） after pancreaticoduodenectomy （PD）， and to provide a reference for the clinical screening and application of POPF-related risk models. Methods: This study was conducted according to the PRISMA guidelines， with a PROSPERO registration number of CRD42023437672. PubMed， Scopus， Embase， Web of Science， the Cochrane Library， CNKI， VIP， Wanfang Data， China Medical Journal Full-text Database， and CBM were searched for studies on establishing risk prediction models for POPF after PD published up to April 26， 2024. The PROBAST tool was used to assess the quality of articles， and RevMan 5.4 and MedCalc were used to perform the Meta-analysis. Results: A total of 36 studies were included， involving 20 119 in total， and the incidence rate of POPF after PD was 7.4%‍ ‍—‍ ‍47.8%. A total of 55 risk prediction models were established in the 36 articles， with an area under the receiver operating characteristic curve （AUC） of 0.690‍ ‍—‍ ‍0.952， among which 52 models had an AUC of >0.7. The quality assessment of the articles showed high risk of bias and good applicability. MedCalc was used to perform a statistical analysis of AUC values， and the results showed a pooled AUC of 0.833 （95% confidence interval： 0.808‍ ‍—‍ ‍0.857）. The Meta-analysis showed that body mass index， amylase in drainage fluid on the first day after surgery， preoperative serum albumin， pancreatic duct diameter， pancreatic texture， fat score， tumor location， blood loss， sex， time of operation， main pancreatic duct index， and pancreatic CT value were predictive factors for POPF （all P<0.05）. Conclusion: The risk prediction models for POPF after PD is still in the exploratory stage. There is a lack of calibration methods and internal validation for most prediction models， and only the univariate analysis is used to for the screening of variables， which leads to the high risk of bias. In the future， it is necessary to improve the methods for model establishment， so as to develop risk prediction models with a higher prediction accuracy. [ABSTRACT FROM AUTHOR]

At present， vascular intervention and surgery are the main methods for the treatment of pancreatic fistula with bleeding after pancreaticoduodenectomy， but these treatment methods have certain drawbacks， such as the complications of pancreatic fistula， bleeding， and abdominal infection after surgical treatment， and interventional treatment sometimes fails to identify the bleeding site. This article reports a case of complex pancreatic fistula with massive venous hemorrhage after pancreaticoduodenectomy treated with Foley catheter balloon compression through the drainage tube sinus. Bleeding was arrested and gastrointestinal fistula was cured after catheter balloon compression and effective drainage， with no complications such as pancreatic pseudocyst， intestinal ischemia， and portal hypertension. [ABSTRACT FROM AUTHOR]

BACKGROUND: To determine the precise frequency of main pancreatic duct (MPD) dilatation within the remnant pancreas at 1 year after pancreatoduodenectomy (PD) and its clinical implications, a prospective multicenter cohort study was performed in patients without MPD dilatation before PD (registry number: UMIN000029662). STUDY DESIGN: Between October 2017 and July 2020, patients with an MPD diameter less than 3 mm who were planned to undergo PD for periampullary lesions at 21 hospitals were enrolled. The primary endpoints were frequency of MPD dilatation at 1 year after PD, and the relationship between MPD dilatation and pancreatic endo- and exocrine function, nutritional status, and fatty liver. Secondary endpoints were risk factors for MPD dilatation at 1 year after PD and time-course change in MPD diameter. RESULTS: Of 200 registered patients, 161 patients were finally analyzed. Pancreatic fistula was the most frequent complication (76; 47.2%). MPD dilatation (MPD > 3 mm) at 1 year after PD was seen in 35 patients (21.7%). Pancreatic exocrine function, assessed by steatorrhea, was significantly impaired in patients with MPD dilatation. However, endocrine function, nutrition status, and fatty liver development were comparable between the 2 groups. In multivariate analysis, the serum total protein level 7.3 g/dL or more was an independent predictor for MPD dilatation at 1 year after PD (odds ratio 3.12, 95% CI 1.31 to 7.15). A mean MPD diameter significantly increased at 6 months after PD and kept plateau thereafter. CONCLUSIONS: MPD dilatation at 1 year after PD was seen in 21.7% of patients and significantly associated with exocrine function impairment but not with endocrine function, nutrition status, or development of fatty liver. [ABSTRACT FROM AUTHOR]

The aim of this meta-analysis was to evaluate the efficacy and safety of robotic pancreaticoduodenectomy (RPD) in improving perioperative aspects and postoperative complications in patients. Methods: We searched PubMed, Embase, Web of Science, and the Cochrane Library database systems for studies that compared RPD with laparoscopic pancreaticoduodenectomy (LPD). Meta-analysis was performed for 24 relevant outcomes, including perioperative outcomes and postoperative complications. Subsequently, a subgroup analysis based on geographical regions was conducted to investigate the impact of regional differences on the perioperative outcomes of the RPD group and the LPD group. Results: This review found 19 studies with 12,731 individuals (3539 RPD and 9192 LPD). In comparison to LPD, RPD had lower rates of Conversion (OR = 0.58, P < 0.00001), Blood Transfusion (OR = 0.59, P = 0.02), Length of Stay (MD = − 0.54, P = 0.01), postoperative complications [Pneumonia (OR = 0.31, P < 0.0001), and Wound Disruption (OR = 0.26, P = 0.0007)], and more thorough lymph node harvesting (MD = 1.25, P = 0.001). Subgroup analysis showed that Blood Transfusion (I2 = 55%, P = 0.02), Conversion (I2 = 30%, P < 0.00001), Length of Stay (I2 = 71%, P = 0.01), and Lymph Node Harvested (I2 = 87%, P = 0.001) were statistically significant. Interestingly, compared to China, other countries had lower rates of Conversion and more lymph nodes harvested for RPD surgery. Conclusion: The benefits of RPD surgery over LPD surgery in terms of therapy and an optimistic short-term prognosis are clearly supported by this study. Moreover, subgroup analysis based on regional differences revealed statistically significant results for Conversion, Length of Stay (days), Number of Lymph Nodes Harvested and the rate of Blood Transfusion, indicating significant variability across regions. This study provides a solid theoretical foundation and basis for the advancement of RPD in clinical practice. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to analyze the outcomes of patients with resectable/borderline resectable PDAC who receive total neoadjuvant therapy vs upfront surgery. Methods and analysis: Patients who were treated at a single institution from 2006 to 2021 were included. The primary outcome was overall survival (OS). Secondary outcomes included disease free survival (DFS), rates of lymph node positivity, and R0 resection. All survival analyses were performed with intention-to-treat. Results: 26 patients received neoadjuvant chemotherapy and radiation (TNT), 28 received neoadjuvant chemotherapy only (NAC), and 168 received upfront surgery. Demographics were comparable across all three groups. Patients who received TNT or NAC had longer OS and DFS compared to the surgery first patients (P < .01). Patients who received TNT had a lymph node positivity rate of 0% at time of surgery compared to 5.3% and 13.3% in the NAC and surgery-first groups, respectively (P < .01). The rate of R0 resection did not differ between groups (P = .17). Conclusion: Patients with resectable/borderline resectable PDAC who receive neoadjuvant therapy have longer OS and RFS relative to those who receive upfront surgery. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate the effectiveness of a modified reconstruction technique-anchored straight stomach reconstruction-in reducing the incidence of delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) and its impact on postoperative nutritional recovery. Methods: A case series analysis of 125 consecutive PD patients was conducted: 104 of them had undergone anchored straight stomach reconstruction (SSR group) and the remaining 21 without (Non-SSR group). The incidence of DGE and the change in postoperative nutritional status (body weight and serum albumin level during 12 months post-surgery) were compared. Results: The incidence of DGE in the SSR group (13%) was significantly lower than that in the Non-SSR group (33%) (P = .018); further the significant DGE (grade B or C) was only 5%. Comparison of nutritional status showed that SSR facilitated a prompt recovery of body weight and serum albumin level at 6 months after PD. At 12 months after surgery, body weight gain was significantly better in the SSR group than in the Non-SSR group (P = .006), and albumin level tended to be higher in the SSR group (P = .071). Conclusion: Straight stomach reconstruction is able to reduce DGE in patients after PD and also improves their postoperative nutritional recovery. [ABSTRACT FROM AUTHOR]

Background: Grade C pancreatic fistula (PF) is the most dangerous complication after pancreaticoduodenectomy (PD) and had not been identified on the early postoperative day yet. In this study, we aimed to introduce a new approach to distinguish grade C from grade B PF by using features on the 5th postoperative day's computed tomography (CT). Materials and Methods: A bicentric prospective cohort study was conducted from August 2021 to October 2023 at the University Medical Center (UMC) and Cho Ray Hospital, Vietnam. Patients who diagnosed pancreatic fistula and underwent a CT scan on the 5th postoperative day were followed up within 90 days after PD. The characteristics of CT scan images were analyzed to differentiate both grades of PF. Results: During 26 months, 77 patients with periampullary cancer underwent PD and met the criteria of the study (46 males, mean age: 57.1 ± 13.7). Of these, 52 patients had biochemical PF and 25 had CRPF (18 grade B PFs and 7 grade C PFs). Specifications on the 5th postoperative day's CT scan that can discriminate grade C from grade B included fluid diffusing throughout abdomen, retroperitoneal abscess, hematoma beneath the liver, size of the fluid collection next to the pancreas (P = 0.031), and size of pancreatojejunostomy anastomosis dehiscence (P = 0.045). Conclusions: Features on CT scan could be used to identify grade C pancreatic fistula from the 5th postoperative day. This result can help surgeons to make a plan for a careful follow-up and early reoperation for those patients. [ABSTRACT FROM AUTHOR]

Background and Objectives: Biliary fistulas (BFs) occur in approximately 3–8% of patients undergoing pancreaticoduodenectomy (PD), and the bile duct diameter ≤ 5 mm is the most important risk factor. The aim of this study was to evaluate the efficacy of biodegradable biliary stents (BSs) in reducing complications in patients undergoing robotic pancreaticoduodenectomy (RPD) with a bile duct diameter of ≤5 mm. Materials and Methods: A retrospective single-centre observational study was conducted. Patients undergoing RPD after the completion of the robotic biliary anastomosis learning curve were included in this study. Only patients with a bile duct diameter ≤ 5 mm were included in the analysis. A prospectively held database was used. The intraoperative time for biliary anastomosis was extracted from surgical videos. Results: Of 30 patients, 20 received no biliary stent (nBS) and 10 received a biodegradable stent (BS). The decision to use a stent was based on product availability. The median operative time for biliary anastomosis was significantly shorter in the BS group compared to the nBS group, at 15 min versus 24 min (p < 0.001). Three patients in the nBS group developed a BF, whereas none were observed in the BS group. No stent migration was observed in any of the patients. Conclusions: The use of biodegradable biliary stents in high-risk biliary anastomosis in RPD appears to effectively reduce the incidence of BFs and may serve as a viable strategy to mitigate early biliary complications. The use of biodegradable stents facilitates a faster and easier biliary anastomosis. These findings suggest a potential benefit of using biodegradable stents in complex biliary reconstruction. However, larger studies are needed to confirm these results. [ABSTRACT FROM AUTHOR]

The prognostic impact of additional resection based on intraoperative frozen section analysis (FSA) of the pancreatic transection margin in patients with pancreatic ductal adenocarcinoma (PDAC) is controversial. The purpose of this study was to evaluate the prognosis based on the results of the first FSA of the pancreatic transection margin (1st FSA) and the clinical significance of additional resection. Patients who underwent pancreaticoduodenectomy for PDAC from 2000 to 2020 at a single center were included. Patients were divided into 3 groups based on the 1stFSA. Survival and prognostic factors were analyzed according to the 1stFSA. A total of 311 patients were included in this study. The 1stFSA was negative in 272 patients (1stFSA-R0) and positive in 39 patients [carcinoma in situ (1stFSA-CIS), 21 patients; invasive carcinoma (1stFSA-IC), 18 patients]. Additional resections were performed on 37 patients [1stFSA-CIS, 20 patients; 1stFSA-IC, 17 patients], and R0 resection was achieved in 34 patients intraoperatively. Comparing median survival time to 1stFSA-R0 (36.4 months), 1stFSA-CIS was comparable (27.8 months, p = 0.276), although 1stFSA-IC was significantly worse (18.8 months, p = 0.001). On multivariate analysis, 1stFSA-IC was an independent prognostic factor (hazard ratio 2.68, 95 % confidence interval 1.16–6.17, p = 0.020). 1stFSA-CIS and 1stFSA-R0 had similar OS, implying that additional resection may be acceptable for 1stFSA-CIS. 1stFSA-IC was still an independent prognostic factor based on additional resection, and the prognostic significance of additional resection is uncertain for 1stFSA-IC. [ABSTRACT FROM AUTHOR]

Background: The Centers for Medicare and Medicaid Services (CMS) price transparency rule tries to facilitate cost-conscious decision-making. For surgical services, such as pancreaticoduodenectomy (PD), factors mediating transparency and real-world reimbursement are not well described. Methods: The Leapfrog Survey was used to identify United States hospitals performing PD. Financial and operational data were obtained from Turquoise Health and CMS Cost Reports. Chi-square tests and modified Poisson regression evaluated associations with reimbursement disclosure. Two-part logistic and gamma regression models estimated effects of hospital factors on commercial, Medicare, and self-pay reimbursements for PD. Results: Of 452 Leapfrog hospitals, 295 (65%) disclosed PD hospital or procedure reimbursements. Disclosing hospitals were larger (beds > 200: 81.0% vs. 71.3%, p = 0.04), reported higher net margins (0.7% vs. − 2.1%, p = 0.04), more likely for-profit (26.1% vs. 6.4%, p < 0.001), and teaching-affiliated (82.0% vs. 65.6%, p < 0.001). Nonprofit status conferred hospitalization reimbursement increases of $8683–$12,329, while moderate market concentration predicted savings up to $5066. Teaching affiliation conferred reimbursement increases of $4589–$16,393 for hospitalizations and $644 for procedures. Top Leapfrog volume ratings predicted an increase of up to $7795 for only Medicare hospitalization reimbursement. Conclusions: Nondisclosure of hospital and procedural reimbursements for PD remains a major issue. Transparency was noted in hospitals with higher margins, size, and academic affiliation. Factors associated with higher reimbursement were non-profit status, academic affiliation, and more equitable market share. Reimbursement inconsistently tracked with PD quality or volume measures. Policy changes may be required to incentivize reimbursement disclosure and translate transparency into increased value for patients. [ABSTRACT FROM AUTHOR]

Simple Summary: The effect of a perioperative blood transfusion on the postoperative short-term outcomes of patients with periampullary malignancies following pancreatoduodenectomy is still a topic of debate within the literature. To address this issue, a partial correlation and mediation analysis were integrated with propensity score matching and weighting, with the objective of examining the influence of intraoperative blood transfusions on postoperative outcomes. After adjusting for intraoperative blood loss, intraoperative transfusion was not found to be associated with postoperative complications in patients undergoing pancreatoduodenectomy. From a clinical perspective, this finding has important implications, as it allows for the consideration of transfusions in pancreatoduodenectomy patients on an as-needed basis, with the confidence that this will not adversely impact postoperative outcomes. Background/Objectives: The aim of this study was to investigate the association between intraoperative blood transfusion (BT) and the short-term outcomes of pancreatoduodenectomy (PD) for patients with periampullary malignancies. Methods: In a retrospective two-center cohort analysis, we utilized a logistic and mixed-effects ordinal regression, nonparametric partial correlation, and mediation analysis, complemented by propensity score matching (PSM) and weighting. Results: A total of 491 patients were included. Of these, 18 (3.7%) received an intraoperative BT. An intraoperative BT was associated with blood loss (odds ratio (OR) per 100 mL = 1.42; 95% CI 1.27 to 1.62; p < 0.001) and relatively high ASA classes (OR = 3.75; 95% CI 1.05 to 17.74; p = 0.041). Intraoperative blood loss (r = 0.27; p < 0.001) but not intraoperative BT (r = 0.015; p = 0.698) was associated with postoperative complications. Intraoperative BT was associated with postoperative complications according to the unadjusted regression (OR = 1.95; 95% CI 1.38–2.42, p < 0.001) but not the multivariable ordinal regression. In the mediation analysis for relative risk (RR), intraoperative BT was beneficial (RR = 0.51; 95% CI: 0.01–0.78), and blood loss (RR = 2.49; 95% CI: 1.75–177.34) contributed to the occurrence of major postoperative complications. After PSM, analyses revealed that an intraoperative BT did not have a significant impact on the rates of postoperative major complications (OR = 1.048; p = 0.919), clinically relevant postoperative pancreatic fistula (OR = 0.573; p = 0.439) or postoperative 90-day mortality (OR = 0.714; p = 0.439). Conclusions: When adjusting for intraoperative blood loss, intraoperative BT is not associated with postoperative complications. [ABSTRACT FROM AUTHOR]

Background: Sarcopenia and sarcopenic obesity, perceived as a reflection of cancer-induced cachexia, are often diagnosed in patients with periampullary malignancies. The pathophysiology of those conditions is multifactorial regarding the tumor microenvironment, immunological response, and the relationship to surrounding tissues. Methods: The PubMed and SCOPUS databases were systematically searched between November 2023 and December 2023. A total of 254 studies were primarily identified. Regarding the inclusion and exclusion criteria, 26 studies were finally included in the review. Results: Evaluated papers disclosed that sarcopenia was significantly associated with a higher incidence of postoperative complications, including pancreatic fistula (POPF) type B and C, with the odds ratio (OR) ranging from 2.65 (95%CI 1.43–4.93, p = 0.002) to 4.30 (95%CI 1.15–16.01, p < 0.03). Sarcopenic patients also suffered more often from delayed gastric emptying (DGE) with an OR of 6.04 (95%CI 1.13–32.32, p = 0.036). Infectious complications, postoperative hemorrhage, and intra-abdominal abscesses occurred more often in sarcopenic patients. Surgical complications were also noted more frequently when sarcopenic obesity was present. Preoperative nutritional prehabilitation seems to reduce the risk of postoperative complications. However, more prospective studies are needed. Conclusions: Sarcopenia and sarcopenic obesity were associated with a higher incidence of multiple postoperative complications, including POPF (type B and C), DGE, hemorrhage, and infectious complications. [ABSTRACT FROM AUTHOR]

Background: Pancreaticoduodenectomy is a highly difficult and invasive type of gastrointestinal surgery. Prevention of postoperative pancreatic fistula is important, and this may be possible by the stapler method. Methods: STRAP-PD is a single center randomized controlled trial. We compare a method of transecting the pancreatic parenchyma in pancreaticoduodenectomy using a surgical stapler device with a conventional transecting method using energy devices (e.g., scalpel, ultrasonic coagulator and incision devices). Patients with soft pancreas who are scheduled to undergo pancreaticoduodenectomy are randomized to arm A (conventional method) or arm B (stapler method). We aim to examine the safety and usefulness of dissection by the automatic suture device, with attention to the rate of pancreatic fistula ISGPF grade B or C and to postoperative complications. This is a single-center randomized study, which began in September 2023 at Wakayama Medical University Hospital. Discussion: Pancreatic parenchymal transection is typically performed either by direct incision using a scalpel or by employing energy devices such as ultrasonic coagulating cutting devices during pancreaticoduodenectomy. In a prospective pilot study, we conducted pancreatic parenchymal transection in 20 consecutive normal pancreatic cases during pancreaticoduodenectomy, observing postoperative pancreatic fistula grade B in one case (5%). Traditional methods involving scalpel incision or the use of ultrasonic coagulating cutting devices have been historically favored but perceived as technically challenging, and they have been reliant upon the surgeon's skill. Notably, relatively high incidences of postoperative pancreatic fistula among patients with soft pancreas have also been observed. Our proposed stapler method may therefore be a useful method responsible for reducing the development of pancreatic fistula. This method would be as part of minimally-invasive surgery for pancreaticoduodenectomy. It uses an endoscopic linear stapler to cut the pancreatic parenchyma, so it is likely to be more convenient than conventional methods and can be used universally. Trial registration: University Hospital Medical Information Network Clinical Trials Registry, UMIN000052089. the Registration Date on 1st September 2023. [ABSTRACT FROM AUTHOR]

Pancreaticoduodenectomy after esophagectomy is a challenging procedure given the need to preserve the vascularization of the gastric plasty. We describe a case of a modified Longmire III procedure in a 68-year-old patient who underwent an esophagectomy with gastric conduit reconstruction in 2019 for esophageal adenocarcinoma. Two years later, an adenocarcinoma of the ampulla of Vater was diagnosed, necessitating pancreaticoduodenectomy with preservation of the gastric conduit. The patient presented no postoperative complications. Hepatic recurrence was observed 13 months after surgical resection. At 24 months follow-up, new liver metastases were observed. Preservation of the gastroduodenal and right gastric arteries was achieved, enabling conservation of the gastric plasty. Given the limitations of lymphadenectomy, the indication for this surgery must always be carefully considered. In the context of complex surgery, a complete preoperative workup to precisely determine the vascular anatomy as well as any anatomical variations is essential to establish the best operative strategy. [ABSTRACT FROM AUTHOR]

Introduction: Pancreaticoduodenectomy (PD) has been the primary curative-intent surgical option for resectable periampullary tumours. Despite advancements in relevant surgical techniques, PD-related morbidity and mortality rates continue to remain high. Therefore, the preoperative identification of high-risk patients is vital for tailoring PD approaches to the individual patient. Aim: To assess early postoperative morbidity and mortality following PD in a tertiary centre in Turkey and identify the associated risk factors. Materials and Methods: This cross-sectional, single-centre study conducted in the General Surgery Clinics of Ankara Numune Training and Education Hospital in Ankara, Turkey included a population of 64 patients undergoing PD for malignant periampullary tumours between May 2010 and May 2014. Patients' demographic, clinical and intraoperative data were collected. The primary outcome of the study was the 30-day postoperative mortality rate. Pearson's Chi-square, Fisher'sexact and Fisher-Freeman-Halton tests were used to compare differences in categorical variables between the groups. Results: The study sample consisted of 64 patients with a mean age of 60.1±12.4 years. The 30-day postoperative mortality rate in the sample was 18.75%. Non survivors were significantly older (age >70 years) (p=0.006), had significantly higher American Society of Anaesthesiologists (ASA) physical status classes (>III) (p=0.008), had significantly lower Neutrophil-to-lymphocyte Ratios (NLR) (<2.5) (p<0.001) and had significantly lower serum albumin levels (<3.5 g/dL) (p=0.038) compared to survivors. The rate of patients experiencing intraoperative blood loss exceeding 1000 mL and consequently the median number of blood units transfused, was significantly higher in non survivors than in survivors (p<0.009 and p<0.001, respectively). Similarly, overall and major complications were significantly more common in non survivors than in survivors (p=0.002 and p=0.012, respectively). Conclusion: The findings of the study indicated that a higher ASA class, older age, lower NLR, hypoalbuminemia, higher intraoperative blood loss, the need for blood transfusion and postoperative complications were associated with increased 30-day mortality after PD. [ABSTRACT FROM AUTHOR]

Objective: Postoperative pancreatic fistula (POPF) is a common and challenging complication following pancreaticoduodenectomy (PD), occurring in 2% to 46% of cases. Despite various pancreaticojejunostomy techniques, an effective method to prevent POPF has not been established. This study aimed to develop and evaluate a novel 3D-printed biodegradable pancreatic duct stent to simplify the surgical process of pancreaticojejunostomy, reduce anastomotic complexity, and minimize postoperative complications. Methods: Data from 32 patients undergoing total laparoscopic pancreaticoduodenectomy were utilized. Preoperative CT scans were transformed into 3D reconstructions to guide the design and printing of customized stents using polylactic acid (PLA). The stents were assessed for mechanical integrity, surface texture, and thermal stability. Animal experiments were conducted on 16 mini pigs, with the experimental group receiving the novel stent and the control group receiving traditional silicone stents. Results: The 3D-printed stents demonstrated accurate dimensional replication and mechanical reliability. In the animal experiments, the experimental group showed no significant difference in postoperative complications compared to the control group. At 4 weeks post-surgery, CT scans revealed well-healed anastomoses in both groups, with no significant inflammation or other complications. Histological examination and 3D reconstruction models confirmed good healing and device positioning in the experimental group. Conclusion: The 3D-printed biodegradable pancreatic duct stent offers a promising solution for pancreaticojejunostomy, with comparable safety and efficacy to traditional methods. Further research is needed to validate its clinical application. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this investigation was to assess the prognostic importance of the combination of preoperative hemoglobin (Hb) levels and Geriatric Nutritional Risk Index (GNRI) in forecasting postoperative survival outcomes for patients undergoing pancreaticoduodenectomy (PD) due to Vater ampulla carcinoma (VPC). Methods: The GNRI nutritional screening was conducted for all patients, and patient outcomes, including overall survival (OS), were subsequently monitored. An H‐ GNRI scoring system was established using the optimal critical values of 125.5 g/L for Hb and 91.72 for GNRI, as determined by X‐tile software. According to the H‐GNRI score, the patients were categorized into three groups, namely low H‐GNRI group (H‐GNRI score = 0, n = 47) with Hb < 125.5 g/L and GNRI < 91.72; medium H‐GNRI group (H‐GNRI score = 1, n = 77) with Hb < 125.5 g/L and GNRI ≥ 91.72, or Hb ≥ 125.5 g/L and GNR < 91.72; and high H‐GNRI group (H‐GNRI score = 2, n = 51) with Hb ≥ 125.5 g/L and GNRI ≥ 91.72. The Kaplan–Meier analysis and log‐rank tests were employed to evaluate the OS rate and compare survival disparities among various groups. Additionally, both univariate and multivariate analyses were conducted utilizing the Cox regression model, with p < 0.05 considered statistically significant. Finally, to evaluate the predictive effectiveness of Hb, GNRI, and H‐GNRI, a receiver operating characteristic (ROC) curve was constructed to compare the area under curve (AUC) values. Results: The OS rate was higher in patients with high Hb levels (≥ 125.5 g/L) compared to those with low Hb levels (< 125.5 g/L). Likewise, patients in the high GNRI group (≥ 91.72) exhibited significantly superior OS compared to those in the low GNRI group (< 91.72). Compared with both the medium and low H‐GNRI groups, the high H‐GNRI group demonstrated a notably higher OS rate. The T stage (HR = 2.523, 95% CI: 1.694–3.757, p < 0.001), N stage (HR = 2.018, 95% CI: 1.255–3.246, p = 0.004), and the H‐GNRI score (H‐GNRI score of 2 used as the baseline; H‐GNRI score of 0: HR = 2.569, 95% CI: 1.499–4.402, p < 0.001; H‐GNRI score of 1: HR = 1.835, 95% CI: 1.118–3.014, p = 0.016), after adjusting for gender, were determined to be independent significant predictors affecting the OS of patients with VPC. The AUC of H‐GNRI was 0.677, exceeding that of Hb levels (0.631) and GNRI (0.615). Conclusions: The combination of preoperative Hb levels and GNRI demonstrates superior predictive efficacy for VPC patients undergoing PD, compared with either Hb levels or GNRI score alone. Therefore, the H‐GNRI score can be utilized to promptly identify high‐risk patients, establish comprehensive nutritional pre‐rehabilitation plans through interdisciplinary collaboration, and inform decisions regarding additional adjunctive therapies. [ABSTRACT FROM AUTHOR]

Simple Summary: We examined the association of the entire submission of the tumor (ESOT) and the entire submission of the pancreas (ESOP) with clinicopathologic features and survival in 627 pancreatic cancer patients who received neoadjuvant therapy (NAT). We demonstrated that both ESOT and ESOP were associated with lower ypT, less frequent perineural invasion, and better tumor response. Both ESOT and ESOP were associated with less frequent recurrence/metastasis, better disease-free survival (DFS), and overall survival (OS) in the overall study population. ESOP was associated with better DFS and OS in patients with ypT0/ypT1 or ypN0 tumors and better OS in patients with complete or near-complete response. ESOT was associated with better OS in patients with ypT0/ypT1 or ypN0 tumors. Both ESOT and ESOP were independent prognostic factors for OS in multivariate survival analyses. Therefore, ESOP and ESOT are associated with the prognosis of PDAC patients with complete or near-complete response and a ypT0/ypT1 tumor after NAT. Adequate sampling is essential to an accurate pathologic evaluation of pancreatectomy specimens resected for pancreatic ductal adenocarcinoma (PDAC) after neoadjuvant therapy (NAT). However, limited data are available for the association between the sampling and survival in these patients. We examined the association of the entire submission of the tumor (ESOT) and the entire submission of the pancreas (ESOP) with disease-free survival (DFS) and overall survival (OS), as well as their correlations with clinicopathologic features, for 627 patients with PDAC who received NAT and pancreaticoduodenectomy. We demonstrated that both ESOT and ESOP were associated with lower ypT, less frequent perineural invasion, and better tumor response (p < 0.05). ESOP was also associated with a smaller tumor size (p < 0.001), more lymph nodes (p < 0.001), a lower ypN stage (p < 0.001), better differentiation (p = 0.02), and less frequent lymphovascular invasion (p = 0.009). However, since ESOP and ESOT were primarily conducted for cases with no grossly identifiable tumor or minimal residual carcinoma in initial sections, potential bias cannot be excluded. Both ESOT and ESOP were associated with less frequent recurrence/metastasis and better DFS and OS (p < 0.05) in the overall study population. ESOP was associated with better DFS and better OS in patients with ypT0/ypT1 or ypN0 tumors and better OS in patients with complete or near-complete response (p < 0.05). ESOT was associated with better OS in patients with ypT0/ypT1 or ypN0 tumors (p < 0.05). Both ESOT and ESOP were independent prognostic factors for OS according to multivariate survival analyses. Therefore, accurate pathologic evaluation using ESOP and ESOT is associated with the prognosis in PDAC patients with complete or near-complete pathologic response and ypT0/ypT1 tumor after NAT. [ABSTRACT FROM AUTHOR]

Background: Since robotic pancreaticoduodenectomy (R-PD) has emerged as a promising technique for treating periampullary tumors, optimal surgical views across various stages of the surgery are vital. This study aimed to describe the evolution and optimization of the multiple scope transition (MST) method using comprehensive videos and illustrations, particularly from the perspective of the patient-side assistants, to enhance the efficiency and safety of R-PD through its different phases. Methods: We retrospectively analyzed 61 patients who underwent R-PD from April 2021 to May 2023. Results: The median total operation duration was 599 min (415–840 min). The median scope transition times for redocking from the left to central lower position, transition from the central lower to upper position, and port-hopping from the central to right position were 169 s (53–725 s), 55 s (26–165 s), and 120 s (41–260 s), respectively. Owing to the advancements in the scope transition procedures, these scope transition times became shorter with an increase in the number of experiences. No intraoperative complications relevant to scope transition was reported, and the incidence of significant postoperative complications greater than Grade IIIa of the Clavien–Dindo classification was 8.2%. Conclusion: We reported the established role and evolution of the MST method from the standpoint of the patient-side assistants. The comfortable surgical field expansion provided by the MST method can ensure the safe and widespread application of R-PD. [ABSTRACT FROM AUTHOR]

Background: There are limited data on the effect of different sutures and surgical approaches on the quality of pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy (MIPD). This study compares the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) between the use of barbed sutures (BSs) and conventional sutures (CSs). Methods: A retrospective cohort study was conducted on 253 consecutive patients who had undergone MIPD from July 2016 to April 2023. Patients were excluded if conversion to open surgery or open anastomosis was necessary. 220 patients were enrolled and divided into BS (n = 148) and CS (n = 72) groups. After 1:1 propensity score matching (PSM), 67 cases remained in each group. Univariate and multivariate analyses identified factors associated with CR-POPF. Comparisons were also made between laparoscopic (LPD) and robotic (RPD) pancreaticoduodenectomy. Results: After PSM, BSs were associated with significantly lower rates of CR-POPF (7.5 vs. 22.4%, P = 0.015) and severe complications (Clavien–Dindo ≥ III) (7.5vs. 19.4%, P = 0.043). No significant differences were found in operative time, length of postoperative hospital stay, or other major morbidities. Multivariate analyses revealed BMI ≥ 22 kg/m2 (OR = 5.048, 95% CI: 1.256–20.287, P = 0.023) and the use of BSs (OR = 0.196, 95% CI: 0.059–0.653, P = 0.008) as the independent predictors of CR-POPF. There were no significant differences in postoperative outcomes between the LPD and RPD groups, but RPD was associated with significantly shorter operative time (402.8 min vs. 429.4 min, P = 0.015). Conclusions: In conclusion, using BSs for PJ during MIPD is feasible and has the potential to reduce CR-POPF and severe complications. [ABSTRACT FROM AUTHOR]

Background: Difficulties in distinguishing fibrosis from tumor in borderline and locally advanced pancreatic adenocarcinoma (PDAC) justify surgical exploration to assess resectability. This issue is especially relevant after neoadjuvant treatments (NAT) prior to pancreaticoduodenectomy (PD) although outcomes of aborted PD are unknown. Objectives: This study aimed to evaluate early outcomes after aborted PD in patients with PDAC. Methods: Data were collected over a ten-year period, in three University Hospitals in France. Perioperative patient management was similar. The causes of intraoperative PD abortions were recorded, and outcomes of patients who underwent early (metastases, carcinomatosis) and late (following extensive vascular dissection) PD abortion were compared. Results: Of 774 PD for PDAC, 131 (17%) were aborted. 97 (74%) patients underwent early PD abortion due to carcinomatosis (n = 14; 14%), liver metastases (n = 32; 33%), aortocaval lymph node invasion (n = 28; 29%) and massive vascular extension (n = 23; 24%). Late PD abortion occurred after extensive vascular dissection in 34 (26%) patients due to invasion of the common hepatic (n = 16; 47%), superior mesenteric (n = 5; 15%) and right hepatic (n = 1; 3%) arteries and nonreconstructable venous invasion (n = 12; 35%). Patients who underwent late PD abortion had higher rates of overall morbidity (n = 22; 65% vs n = 27; 28%, p = 0.0001), severe complications (n = 14; 41% vs n = 11; 11%, p = 0.0005), mortality (n = 4; 12% vs n = 0; 0%, p = 0.003). They also had higher rates of delayed gastric emptying (n = 11; 32% vs n = 6; 6%, p = 0.0003), deep space infections (n = 10; 29% vs n = 7; 7%, p = 0.002), wound infections (n = 5; 15% vs n = 4; 4%, p = 0.05), and bleeding (n = 8; 24% vs n = 0; 0%, p < 0.0001). Conclusion: Aborted PD after extensive vascular dissection has high morbidity and mortality rates. Appropriate information and counseling should be delivered to patients with borderline/locally advanced PDAC considered for PD. [ABSTRACT FROM AUTHOR]

Background: Simulation and video-based assessment (VBA) offer residents the opportunity to develop operative skills while ensuring patient safety. This study aims to determine whether simulation training can predict residents' operative performance, focusing on the gastrojejunal (GJ) anastomosis during robotic pancreatoduodenectomy. Methods: Twenty-seven general surgery residents completed simulated robotic GJ drills and subsequently performed GJs in the operating room (OR). Both simulated and intraoperative performances were video recorded and retrospectively assessed by two blinded graders using the Objective Structural Assessment of Technical Skills (OSATS) scale, time to completion, and occurrence of errors. Intraoperative GJ OSATS scores were compared in cases with and without Clinically Relevant Delayed Gastric Emptying (CRDGE). Statistical analysis was performed using Spearman's rho, Chi-square, and Kruskal–Wallis tests. Results: For simulated GJs, the median OSATS score was 29 (IQR 27–33), time to completion was 30 min (IQR 27–35), and 11 cases had at least one error. Intraoperative GJs had a median OSATS of 30 (IQR 27–31), time to completion of 41 min (IQR 36–51), and errors occurred in nine cases. The OSATS score on the simulated GJs demonstrated a significant positive correlation to the OSATS score on the operative GJs (r = 0.74; p < 0.001) and less time to completion (r = − 0.68; p < 0.001). A shorter simulated GJ completion time significantly correlated with a higher intraoperative OSATS score (r = − 0.52; p < 0.01). Residents with at least one error in the simulated GJs had lower OSATS scores and higher times intraoperatively. Those cases with CRDGE had significantly lower intraoperative OSATS scores than those without CRDGE. Conclusion: Performance on a simulated robotic GJ environment is a robust predictor of OR GJ performance, demonstrating predictive validity. VBA of residents' operative GJ performance is associated with the presentation of CRDGE. Simulation-based training may be crucial to optimizing surgical outcomes before operating on patients. [ABSTRACT FROM AUTHOR]

Background: Conservative treatment of chronic pancreatitis has only a limited effect in most patients. Surgery offers very good long-term results, even in the early stages of the disease. Unfortunately, only a minority of patients undergo surgical treatment. The aim of this work was to summarise the current treatment options for patients with an inflammatory mass of the pancreatic head. Data from patients in our study demonstrates that the surgery is a safe method, and here we compare the perioperative and early postoperative outcomes of patients who underwent a pancreatoduodenectomy and duodenum-preserving pancreatic head resection for chronic pancreatitis. Methods: All patients who underwent a pancreaticoduodenectomy or a duodenum-preserving pancreatic head resection in our department between 2014 and 2022 were included in this study. Perioperative and early postoperative results were statistically analysed and compared. Results: Thirty-eight pancreaticoduodenectomies and 23 duodenum-preserving pancreatic head resections were performed. The overall mortality was 3%, whereas the in-hospital mortality after pancreaticoduodenectomy was 5%. The mortality after duodenum-preserving pancreatic head resection was 0%. No statistically significant differences in the hospital stay, blood loss, and serious morbidity were found in either surgery. Operative time was significantly shorter in the duodenum-preserving pancreatic head resection group. Conclusions: Both pancreatoduodenectomy and duodenum-preserving pancreatic head resection are safe treatment options. Duodenum-preserving pancreatic head resection showed a statistically significant superiority in the operative time compared to pancreaticoduodenectomy. Although other monitored parameters did not show a statistically significant difference, the high risk of complications after pancreaticoduodenectomy with a mortality of 5%; maintenance of the duodenum and upper loop of jejunum, and lower risk of metabolic dysfunctions after duodenum-preserving pancreatic head resection may favour duodenum-preserving pancreatic head resection in recommended diagnoses. Attending physicians should be more encouraged to use a multidisciplinary approach to assess the suitability of surgical treatment in patients with chronic pancreatitis. [ABSTRACT FROM AUTHOR]

Background The effects of postoperative pancreatic fistula on survival rates remain controversial. The aim of the present study was to evaluate the influence of postoperative pancreatic fistula on overall survival and recurrence-free survival after upfront pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Methods Patients operated on between January 2007 and December 2017 at seven tertiary pancreatic centres for pancreatic ductal adenocarcinoma were included in the study. Postoperative pancreatic fistula was defined using the 2016 International Study Group on Pancreatic Surgery grading system. The impact of postoperative pancreatic fistula on overall survival, recurrence-free survival (excluding 90-day postoperative deaths) and corresponding risk factors were investigated by univariable and multivariable analyses. Comparisons between groups were made using the chi-squared or Fisher's exact test for categorical variables and the Mann–Whitney U test for continuous variables. Odds ratios were estimated with their 95% confidence intervals. Survival rates were calculated using the Kaplan–Meier method with their 95% confidence intervals. Results A total of 819 patients were included between 2007 and 2017. Postoperative pancreatic fistula occurred in 14.4% (n = 118) of patients; of those, 7.8% (n = 64) and 6.6% (n = 54) accounted for grade B and grade C postoperative pancreatic fistula respectively. The 5-year overall survival was 37.0% in the non-postoperative pancreatic fistula group and 45.3% in the postoperative pancreatic fistula cohort (P = 0.127). Grade C postoperative pancreatic fistula (excluding 90-day postoperative deaths) was not a prognostic factor for overall survival. The 5-year recurrence-free survival was 26.0% for patients without postoperative pancreatic fistula and 43.7% for patients with postoperative pancreatic fistula (P = 0.003). Eight independent prognostic factors for recurrence-free survival were identified: age over 70 years, diabetes, moderate or poor tumour differentiation, T3/T4 tumour stage, lymph node positive status, resection margins R1, vascular emboli and perineural invasion. Conclusion This high-volume cohort showed that grade C postoperative pancreatic fistula, based on the 2016 International Study Group on Pancreatic Surgery grading system, does not impact overall or recurrence-free survival (excluding 90-day postoperative deaths). [ABSTRACT FROM AUTHOR]

Background: Clinically relevant‐postoperative pancreatic fistula (CR‐POPF) is one of the dreaded complications of pancreatoduodenectomy. Vascularity of the stump of the pancreas during pancreatico‐enteric anastomosis is considered one of the major determinants of POPF. Indocyanine green (ICG) is one of the modality for vascular assessment; hence, we aimed to evaluate the role of ICG fluorescence imaging to assess the vascularity of the pancreatic stump during pancreatoduodenectomy. Methodology: The study was conducted at Kathmandu Medical College, Kathmandu, Nepal, during the period of 1 year (June 01, 2022–July 31, 2023). All of the patients who were undergoing pancreatoduodenectomy were included in the study. In all cases, intraoperatively, ICG fluorescence detection at the pancreatic stump margin was evaluated using near‐infrared light. Results: A total of 28 patients underwent PD during this period. The ICG fluorescence imaging was positive at the pancreatic stump margin in 25 out of the 28 patients (89%), and in three cases, the florescence was negative. In patients who had negative fluorescence, revision of the stump margin was performed. Clinically relevant POPF was noted in 2 out of 28 cases, which had a soft pancreas with a small duct, although the pancreatic stump margin had good ICG florescence per‐operatively. Conclusion: ICG is inexpensive and a safe dye to use in clinical practice. We can objectively assess the pancreatic stump vascularity using intraoperative ICG fluorescence imaging, thereby potentially decreasing postoperative pancreatic fistula. [ABSTRACT FROM AUTHOR]

Background: Anemia is a common long‐term metabolic sequela caused by anatomical changes after major gastrointestinal surgery, such as bariatric surgery and gastrectomy. Pancreaticoduodenectomy (PD) involves resection of the duodenum and enteral bypass, which may contribute to malabsorption and nutrient deficiency. Hence, PD may cause anemia. Methods: This study included 322 patients who presented with PD during the 5‐year follow‐up from 2006 to 2017. The Kaplan–Meier method and the Cox regression model were used to investigate the association between risk factors and anemia. Results: Approximately 44.4% of patients developed post‐PD anemia during the 5‐year post‐PD follow‐up. Further, 30 (9.3%) patients were treated with oral iron supplementation for anemia with associated symptoms. In the Cox multivariate model, a higher Charlson Comorbidity Index (CCI) score and pancreatic ductal adenocarcinoma were significantly associated with the development of post‐PD anemia. Conclusion: Post‐PD anemia is a common sequela among long‐term survivors. A higher CCI and pancreatic ductal adenocarcinoma diagnosis were considered as independent risk factors for post‐PD anemia. Therefore, regular monitoring of hematological profiles and appropriate management of post‐PD anemia are required during follow‐up. [ABSTRACT FROM AUTHOR]