Open vs robotic-assisted pancreaticoduodenectomy, cost-effectiveness and long-term oncologic outcomes: a systematic review and meta-analysis.

BACKGROUND: Whipple pancreaticoduodenectomy (PD) is a complex gastrointestinal surgery that is performed increasingly via minimally invasive approach through robotic platforms. We sought to provide a comparative review of available data regarding robot-assisted vs open PD in terms of cost-effectiveness, overall survival, and other perioperative and long-term oncologic outcomes. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria, PubMed, Scopus, and Web of Science databases were searched from 1980 to April 2024 using designated keywords. English-language studies comparing costs and oncologic outcomes of robotic vs open PDs were considered for inclusion. Reviews, abstracts, case reports, letters to the editor, and non-English articles were excluded. RESULTS: A total of 1733 studies were initially identified throughout the literature search. After the removal of duplicates, title and abstract screening identified 16 studies that were included in the review. No statistically significant differences were detected in terms of short-term complications (95% CI, 0.805-1.096; P = .42), mortality (95% CI, 0.599-1.123; P = .21), and readmission (95% CI, 0.959-1.211; P = .20) among patients undergoing open vs robotic PD. Robotic PDs was associated with a slightly better overall survival (95% CI, 1.020-1.233) and higher costs (95% CI, 0.134-1.139; P = .013). Mean length of stay (LOS) was higher in the open PD group (95% CI, -0.353 to 0.189; P < .001). CONCLUSION: Robotic-assisted PD had a slightly shorter LOS and improved overall survival. There were no differences in short-term complications, mortality, or readmission. The use of cohort studies and residual potential selection bias necessitate randomized controlled trials to define the benefit of robotic PD.

Outcomes of minimally invasive vs. open pancreatoduodenectomies in pancreatic adenocarcinoma: analysis of ACS-NSQIP data.

INTRODUCTION: Pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) presents a significant challenge owing to its aggressive nature. Traditionally performed as open surgery, the advent of minimally invasive surgery (MIS) including laparoscopic and robotic techniques, offers a potential alternative. This study assessed the use and outcomes of MIS and open PD for PDAC treatment. METHODS: We analyzed ACS-NSQIP data (2015-2021) using regression models to compare patient outcomes across open PD, MIS PD, and conversions from MIS to open (MIS-O). RESULTS: Of 19,812 PDAC patients, 1,293 (6.53%) underwent MIS, 18,116 (91.44%) underwent open PD, and 403 (2.03%) underwent MIS converted to open PD (MIS-O). The MIS rate increased from 6.1% to 9.2%. Black patients had a higher MIS-O rate (RR, 1.55; p = 0.025). Open PD was associated with more severe conditions (ASA ≥ III, malnutrition) and prior radiation therapy. MIS patients more often had neoadjuvant chemotherapy. Complex procedures, such as vein resection, favored open PD. Need for arterial resection was associated with MIS-O (RR, 2.11; p = 0.012), and operative time was significantly associated with MIS (OR: 4.32, 95% CI: 3.43-5.43, p-value: < 0.001) No differences in the overall morbidity or 30-day mortality were observed. MIS led to shorter stays but higher risks of reoperation and pulmonary embolism. MIS-O increased the delayed gastric emptying rate (RR, 1.79; p < 0.001). CONCLUSION: During 2015-2021, an increasing number of patients with PDAC are undergoing MIS PD. Morbidity and mortality did not differ between open and MIS PD. MIS was performed more frequently in patients with better nutritional status and lower ASA, or when vascular resection was not anticipated. In well selected patients, short-term outcomes of MIS and open PD seem similar.

Partial pancreatoduodenectomy versus total pancreatectomy in patients with preoperative diabetes mellitus: Comparison of surgical outcomes and quality of life.

PURPOSE: To reduce perioperative risks among patients with a preoperative diabetes mellitus (DM) a total pancreatectomy (TP) might be a alternative to pancreatoduodenectomy (PD). This study aimed to compare the postoperative quality of life (QoL) of patients with preoperative DM undergoing PD or TP. METHODS: A single-centre retrospective study was conducted, all consecutive patients with preoperative DM undergoing PD or TP between 2011 and 2023 were identified in a prospective database. The primary endpoint was QoL, prospectively assessed using EORTC QLQ-C30 questionnaires at 3, 6, and 12 months after surgery and then annually until death. Secondary endpoints were morbidity and mortality. RESULTS: Seventy-one patients were included, 17 after TP and 54 after PD. Insulin-dependent DM occurred in 21 (39%) of the PD patients. QoL was worse after TP, especially in terms of physical functioning (-31.7 points; 95% CI: -50.0 to -13.3; P < 0.001), role functioning (-41.3 points; 95% CI: -61.3 to -21.3; P < 0.001), emotional functioning (-27.5 points; 95% CI: -50.4 to -4.6; P = 0.019), fatigue symptoms (20 points; 95% CI: 2.7 to 37.4; P = 0.024) and pain symptoms (30.2 points; 95% CI: 4.1 to 56.3; P = 0.024). The rates of postoperative major complications (29% vs. 35%; P = 0.853) and mortality (11% vs. 7%; P = 0.857) were similar between TP and PD. CONCLUSION: Postoperative morbidity and mortality were comparable between PD and TP, however QoL is significantly lower after TP. Importantly, patients with preoperative DM have a 60% chance of remaining noninsulin-dependent after PD.

Graft Choice in Pancreatectomy with Vascular Resection: Equivalent Safety in Selected Patients.

BACKGROUND: Pancreatic cancer is the third leading cause of cancer related death in the US, with surgical resection being the only option for long term survival. The ability to manage vascular involvement has expanded the pool of patients who are able to undergo resection with curative intent. However, not all vascular involvement can be detected pre-operatively. We investigated patterns of vascular resection and methods of repair or reconstruction METHODS: Single center retrospective review of adult patients undergoing pancreatectomy with vascular involvement at a tertiary care referral hospital between 2010-2022. Our primary endpoint was graft thrombosis within 90 days. RESULTS: 147 patients were included in the study. 21.8% of whom were not suspected of having vascular involvement pre-operatively. 68% of patients required vascular reconstruction (68%) with the remaining 32% undergoing repair (either primary repair or patch angioplasty). The majority undergoing reconstruction underwent primary end to end anastomosis (63%), with 19 patients requiring autogenous interposition grafts and 16 patients requiring Cryovein® interposition grafts. Univariate analysis found no clinical or technical predictors of early or 90 day thrombosis, including graft choice. 30 and 90 day mortality occurred in 1 and 7 patients respectively. CONCLUSION: Pancreatectomy with vascular resection can be performed with low mortality in carefully selected patients. Unsuspected vascular involvement is relatively common (1 in 5). If autologous graft is not readily available, Cryovein® is a safe alternative with similar perioperative outcomes.

Radicality and safety of total mesopancreatic excision in pancreatoduodenectomy: a systematic review and meta-analysis.

BACKGROUND: Pancreatic head cancer patients who undergo pancreatoduodenectomy (PD) often experience disease recurrence, frequently associated with a positive margin status (R1). Total mesopancreas excision (TMpE) has emerged as a potential approach to increase surgical radicality and minimize locoregional recurrence. However, its effectiveness and safety remain under evaluation. METHODS: We conducted a systematic review and meta-analysis to synthesize current evidence on TMpE outcomes. A systematic search of MEDLINE, EMBASE, Cochrane, and Web of Science databases was conducted up to March 2024 to identify studies comparing TMpE with standard pancreatoduodenectomy (sPD). The risk ratio (RR) or mean difference (MD) was pooled using a random effects model. RESULTS: From 452 studies identified, 9 studies with a total of 738 patients were included, with 361 (49%) undergoing TMpE. TMpE significantly improved the R0 resection rate (RR 1.24; 95% CI 1.11-1.38; P < 0.05), reduced blood loss (MD -143.70 ml; 95% CI -247.92, -39.49; P < 0.05), and increased lymph node harvest (MD 7.27 nodes; 95% CI 4.81, 9.73; P < 0.05). No significant differences were observed in hospital stay, postoperative complications, or mortality between TMpE and sPD. TMpE also significantly reduced overall recurrence (RR 0.53; 95% CI 0.35-0.81; P < 0.05) and local recurrence (RR 0.39; 95% CI 0.24-0.63; P < 0.05). Additionally, the risk of pancreatic fistula was lower in the TMpE group (RR 0.66; 95% CI 0.52-0.85; P < 0.05). CONCLUSION: Total mesopancreas excision significantly increases the R0 resection rate and reduces locoregional recurrence while maintaining an acceptable safety profile when compared with standard pancreatoduodenectomy. Further prospective randomized studies are warranted to determine the optimal surgical approach for total mesopancreatic resection.

Are Antibiotics of Value for a Whipple Procedure?

Pancreatoduodenectomy is a complex surgical procedure with a high rate of morbidity, of which surgical-site infections (SSIs) make a large portion. Reduction of SSI rates is critical to decrease hospital lengths of stay, readmissions, delays in adjuvant therapies, and financial health care burden. Current clinical guidelines recommend the administration of cefoxitin as surgical prophylaxis prior to pancreatoduodenectomy. In April 2023, a randomized controlled trial was published in JAMA which showed that piperacillin-tazobactam as perioperative surgical prophylaxis prior to pancreatoduodenectomy decreased 30 day SSI rates (primary outcome), clinically relevant postoperative pancreatic fistula, postoperative sepsis, and Clostridium difficile infection rates.

Rapid deterioration of steatotic liver disease due to portal vein stenosis after pancreaticoduodenectomy.

Steatotic liver disease after pancreatoduodenectomy occurs due to various factors, such as exocrine pancreatic insufficiency, impaired intestinal absorption, and malnutrition. The mechanism of steatogenesis differs to that of conventional steatotic liver disease associated with obesity and insulin resistance. We experienced a rare case of rapidly progressive steatotic liver disease accompanied by portal vein stenosis in the early postoperative period after subtotal stomach-preserving pancreaticoduodenectomy for distal cholangiocarcinoma. Although there was a complication due to postoperative drain infection, the patient was discharged from hospital with no nutritional problems. Two months postoperatively, the patient presented to the emergency room with dyspnea. CT showed a markedly steatotic liver, ascites, and portal vein stenosis. A portal vein stent was inserted transhepatically and the steatotic liver disease gradually improved. During the postoperative course, there were no problems indicated by nutritional markers; although the patient had diarrhea associated with postoperative pancreatic exocrine insufficiency, the symptoms were mild and improved after administration of oral pancrelipase. Before the intervention, the patient had intestinal edema, exacerbation of diarrhea, and a low serum zinc concentration, suggesting that impaired absorption caused by intestinal blood stasis and gut barrier dysfunction contributed to the development of steatotic liver disease.

Early bifurcation of the common hepatic artery: A pitfall that should be known and recognized.

Early bifurcation of the common hepatic artery (EBCHA) is a rare anatomical variation (1%), that is often overlooked but can lead to accidental ligation of the right branch of the hepatic artery with consequent arterial ischemia of the right liver and potentially very serious complications during pancreaticoduodenectomy, partial hepatectomy, or liver harvesting for transplantation. It may be difficult to diagnose EBCHA using transverse imaging sections. However, on standard CT sections with intravenous contrast injection, three warning signs should allow the image reader to suspect it: presence of two hepatic arteries to the right of the celiac trunk, presence of a retro-portal hepatic artery, and absence of a right hepatic artery arising from the superior mesenteric artery. Analysis of the CT with reconstruction then allows for definitive diagnosis and limits the risk of accidental arterial injury or ligation.

Portuguese Pancreatic Club Perspectives on Endoscopic Ultrasound-Guided and Surgical Treatment of Pancreatic Neuroendocrine Tumors.

Pancreatic neuroendocrine tumors (panNETs) are a group of neoplasms with heterogenous biological and clinical phenotypes. Although historically regarded as rare, the incidence of these tumors has been increasing, mostly owing to improvements in the detection of small, asymptomatic tumors with imaging. The heterogeneity of these lesions creates significant challenges regarding diagnosis, staging, and treatment. Endoscopic ultrasound (EUS) has improved the characterization of pancreatic lesions. Furthermore, EUS nowadays has evolved from a purely diagnostic modality to allow the performance of minimally invasive locoregional therapy for pancreatic focal lesions. The choice of treatment as well as the treatment goals depend on several factors, including tumor secretory status, grading, staging, and patient performance status. Surgery has been the mainstay for the management of these patients, particularly for localized, low-grade, large panNETs >2 cm. Over the last decade, a significant body of evidence has been accumulated evaluating the role of EUS for the ablative therapy of panNETs, namely by the use of chemoablative agents and radiofrequency. Although endoscopic techniques are not routinely recommended by international guidelines, they may be considered for the treatment of smaller lesions in patients who are unwilling or unfit for pancreatic surgery. In this review, we summarize the existing evidence on the interventional techniques for the treatment of patients with panNETs, focusing on the EUS-guided and surgical approaches.

Os tumores neuroendócrinos do pâncreas (panNETs) são um grupo de neoplasias com comportamento biológico e clínico heterogéneo. Embora historicamente considerados raros, a incidência desses tumores tem aumentado, algo que se atribui principalmente à melhoria na deteção de pequenos tumores assintomáticos em exames de imagem. A heterogeneidade destas lesões cria desafios significativos no que respeita ao seu diagnóstico, estadiamento e tratamento. A ultrassonografia endoscópica melhorou a caracterização das lesões pancreáticas. Concomitantemente, a ultrassonografia endoscópica, para além da vertente diagnóstica, evoluiu no sentido do desenvolvimento de capacidades terapêuticas, permitindo a realização de terapêutica locorregional de lesões pancreáticas focais de forma minimamente invasiva.A seleção do tratamento, bem como a definição dos seus objetivos, depende de diversos fatores, incluindo a atividade secretora da neoplasia, a sua atividade mitótica, o estadiamento e o status funcional do doente. A cirurgia é considerada a pedra basilar do tratamento destes doentes, particularmente para panNETs localizados, de baixo grau, com >2 cm. Ao longo da última década foi gerado um conjunto significativo de evidência relativamente ao papel da ultrassonografia endoscópica na terapêutica ablativa dos panNETs, nomeadamente através da utilização de agentes quimioablativos e de radiofrequência. Embora as recomendações internacionais não recomendem a utilização rotineira destas técnicas para o tratamento dos panNETs, as mesmas podem ser consideradas no tratamento de lesões de menores dimensões em doentes que não desejem ou que sejam considerados inaptos para cirurgia pancreática. Esta revisão visa resumir a evidência existente relativa às técnicas de intervenção para o tratamento de pacientes com panNETs, com foco nas abordagens cirúrgica e guiada por ultrassonografia endoscópica.

Reduced-port robotic pancreaticoduodenectomy with optimized surgical field deployment: early results of single-site plus-two ports method.

BACKGROUND: The adoption of Robotic Pancreaticoduodenectomy (RPD) is increasing globally. Meanwhile, reduced-port RPD (RPRPD) remains uncommon, requiring robot-specific techniques not possible with laparoscopy. We introduce a unique RPRPD technique optimizing surgical field exposure. METHODS: Our RPRPD utilizes a single-site plus-two ports technique, facilitated by a single-port platform through a 5-cm incision. The configuration of robotic arms (arm1, arm2, arm3, and arm4) were strategically designed for optimal procedural efficiency, with the arms2 and arm3, alongside the assistant trocar, mounted on the single-port platform, while the arms1 and arm4 were positioned laterally across the abdomen. Drainage was established via channels created at the arm1 and arm4 insertion sites. A "gooseneck traction" was principally employed with the robotic instrument to prop up the specimen rather than grasp, improving the surgical field's visibility and access. Clinical outcomes of patients who underwent RPRPD performed between August 2020 and September 2023 by a single surgeon across two centers in Taiwan and Japan were reviewed. RESULTS: Fifty patients underwent RPRPD using the single-site plus-two ports technique. The gooseneck traction technique enabled goodsurgical field deployment and allowed for unrestricted movement of robotic arms with no collisions with the assistant instruments. The median operative time was 351 min (250-488 min), including 271 min (219-422 min) of console time and three minutes (2-10 min) of docking time. The median estimated blood loss was 80 mL (1-872 mL). All RPRPD procedures were successfully performed without the need for conversion to open surgery. Postoperative major morbidity (i.e., Clavien-Dindo grade ≥ IIIa) was observed in 6 (12%) patients and median postoperative hospital stay was 13 days. CONCLUSIONS: The single-site plus-two ports RPRPD with the gooseneck traction proves to be a safe, feasible option, facilitating surgical field visibility and robotic arm maneuverability.

Laparoscopic Versus Open Pancreatoduodenectomy for Periampullary Tumors: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: Laparoscopic pancreatoduodenectomy (LPD) has emerged as an alternative to open technique in treating periampullary tumors. However, the safety and efficacy of LPD compared to open pancreatoduodenectomy (OPD) remain unclear. Thus, we conducted an updated meta-analysis to evaluate the efficacy and safety of LPD versus OPD in patients with periampullary tumors, with a particular focus on the pancreatic ductal adenocarcinoma patient subgroup. METHODS: According to PRISMA guidelines, we searched PubMed, Embase, and Cochrane Library in December 2023 for randomized controlled trials (RCTs) that directly compare LPD versus OPD in patients with periampullary tumors. Endpoints and sensitive analysis were conducted for short-term endpoints. All statistical analysis was performed using R software version 4.3.1 with a random-effects model. RESULTS: Five RCTs yielding 1018 patients with periampullary tumors were included, of whom 511 (50.2%) were randomized to the LPD group. Total follow-up time was 90 days. LPD was associated with a longer operation time (MD 66.75; 95% CI 26.59 to 106.92; p = 0.001; I2 = 87%; Fig. 1A), lower intraoperative blood loss (MD - 124.05; 95% CI - 178.56 to - 69.53; p < 0.001; I2 = 86%; Fig. 1B), and shorter length of stay (MD - 1.37; 95% IC - 2.31 to - 0.43; p = 0.004; I2 = 14%; Fig. 1C) as compared with OPD. In terms of 90-day mortality rates and number of lymph nodes yield, no significant differences were found between both groups. CONCLUSION: Our meta-analysis of RCTs suggests that LPD is an effective and safe alternative for patients with periampullary tumors, with lower intraoperative blood loss and shorter length of stay.

Artificial intelligence automated surgical phases recognition in intraoperative videos of laparoscopic pancreatoduodenectomy.

BACKGROUND: Laparoscopic pancreatoduodenectomy (LPD) is one of the most challenging operations and has a long learning curve. Artificial intelligence (AI) automated surgical phase recognition in intraoperative videos has many potential applications in surgical education, helping shorten the learning curve, but no study has made this breakthrough in LPD. Herein, we aimed to build AI models to recognize the surgical phase in LPD and explore the performance characteristics of AI models. METHODS: Among 69 LPD videos from a single surgical team, we used 42 in the building group to establish the models and used the remaining 27 videos in the analysis group to assess the models' performance characteristics. We annotated 13 surgical phases of LPD, including 4 key phases and 9 necessary phases. Two minimal invasive pancreatic surgeons annotated all the videos. We built two AI models for the key phase and necessary phase recognition, based on convolutional neural networks. The overall performance of the AI models was determined mainly by mean average precision (mAP). RESULTS: Overall mAPs of the AI models in the test set of the building group were 89.7% and 84.7% for key phases and necessary phases, respectively. In the 27-video analysis group, overall mAPs were 86.8% and 71.2%, with maximum mAPs of 98.1% and 93.9%. We found commonalities between the error of model recognition and the differences of surgeon annotation, and the AI model exhibited bad performance in cases with anatomic variation or lesion involvement with adjacent organs. CONCLUSIONS: AI automated surgical phase recognition can be achieved in LPD, with outstanding performance in selective cases. This breakthrough may be the first step toward AI- and video-based surgical education in more complex surgeries.

A comparison of pancreatojejunostomy using the modified Blumgart anastomosis with or without a four-needle three-loop suture device and continuous sutures for duct-to-mucosa anastomosis in robotic pancreaticoduodenectomy.

PURPOSE: Despite descriptions of different pancreatojejunostomy procedures using robotic pancreaticoduodenectomy (RPD), a standardized procedure has not yet been established. No prior report has described pancreatojejunostomy by RPD combined with modified Blumgart anastomosis with continuous suturing for duct-to-mucosa anastomosis. This study investigated this surgical technique and evaluated the short-term outcomes of the simplified pancreatojejunostomy procedure. METHODS: Between December 2021 and March 2024, 36 patients underwent pancreatojejunostomy using modified Blumgart anastomosis with continuous suturing for duct-to-mucosa anastomosis using RPD. Patients were divided into an early group (n = 15), without the use of the new four-needle three-loop suture device during the modified Blumgart anastomosis and a late group (n = 21) that did use this device. RESULTS: The late group had a significantly shorter pancreatojejunostomy duration (60 min vs. 49 min, p = 0.004) than the early group. Both groups showed equivalent postoperative outcomes; however, the late group exhibited a trend toward a lower rate of postoperative pancreatic fistula grade ≥ B (26.7% vs. 4.8%, p = 0.138). CONCLUSIONS: Pancreatojejunostomy using modified Blumgart anastomosis with a four-needle three-loop suture device and continuous suture for duct-to-mucosa anastomosis in patients undergoing RPD is simple and effective. This new suturing device may further reduce the incidence of postoperative pancreatic fistulas.

Surgical prophylaxis in pancreatoduodenectomy: Is cephalosporin still the drug of choice in patients with biliary stents in situ?

BACKGROUND: Universal surgical prophylaxis for pancreatoduodenectomy (PD) is practiced, with cephalosporins recommended in most guidelines. Recent studies suggest piperacillin-tazobactam (PTZ) prophylaxis in biliary-stented patients is superior in preventing surgical site infections (SSIs). This study aims to refine surgical prophylaxis recommendations based on the local microbial profile and evaluate the clinical outcomes of biliary-stented compared with non-stented patients. METHODS: This was a retrospective study of all consecutive PD patients at Singapore General Hospital between January 2013 to December 2019. The primary outcome was post-operative SSI rates. Secondary outcomes included rates of ceftriaxone-resistant Klebsiella pneumoniae, Escherichia coli, and Enterococcus species from intraoperative bile cultures and 30-day mortality. RESULTS: There were 130 biliary-stented and 211 non-stented patients included. Majority of biliary-stented patients received ceftriaxone ± metronidazole prophylaxis (83/130, 63.8 %) while 30/130 (23.8 %) received PTZ. Most non-stented patients received ceftriaxone ± metronidazole prophylaxis (163/211, 77.3 %). Between biliary-stented and non-stented patients, post-operative SSIs (40.8 % vs 38.4 %, p = 0.662), and 30-day mortality rates (1.5 % vs 1.4 %, p = 1.000) were comparable. The adjusted odds of post-operative SSIs was significantly lower in biliary-stented patients prescribed PTZ as compared to non-PTZ prophylaxis (0.29, 95 % CI (0.10-0.79), p = 0.015). Ceftriaxone-resistant Klebsiella spp. and/or Escherichia coli (27.6 % vs 3.8 %, p < 0.001) as well as Enterococcus species (46.1 % vs 11.5 %, p < 0.001), were more prevalent in intraoperative bile cultures of biliary-stented patients, while frequencies in non-stented patients were low. CONCLUSION: PTZ prophylaxis effectively reduced SSIs in stented patients post-pancreatoduodenectomy. Based on the local microbial profile, ceftriaxone prophylaxis may be used for prophylaxis in non-stented patients.

Learning curve of robotic pancreatoduodenectomy by a single surgeon with extensive laparoscopic pancreatoduodenectomy experience.

With the development of robotic systems, robotic pancreatoduodenectomies (RPDs) have been increasingly performed. However, the number of cases required by surgeons with extensive laparoscopic pancreatoduodenectomy (LPD) experience to overcome the learning curve of RPD remains unclear. Therefore, we aimed to analyze and explore the impact of different phases of the learning curve of RPD on perioperative outcomes. Clinical data were prospectively collected and retrospectively analyzed for 100 consecutive patients who underwent RPD performed by a single surgeon. This surgeon had previous experience with LPD, having performed 127 LPDs with low morbidity. The learning curve for RPD was analyzed using the cumulative sum (CUSUM) method based on operation time, and perioperative outcomes were compared between the learning and proficiency phases. Between April 2020 and November 2022, one hundred patients (56 men, 44 women) were included in this study. Based on the CUSUM curve of operation time, the learning curve for RPD was divided into two phases: phase I was the learning phase (cases 1-33) and phase II was the proficiency phase (cases 34-100). The operation time during the proficiency phase was significantly shorter than that during the learning phase. In the learning phase of RPD, no significant increases were observed in estimated blood loss, conversion to laparotomy, severe complications, postoperative pancreatic hemorrhage, clinical pancreatic fistula, or other perioperative complications compared to the proficiency phases of either RPD or LPD. A surgeon with extensive prior experience in LPD can safely surmount the RPD learning curve without increasing morbidity in the learning phase. The proficiency was significantly improved after accumulating experience of 33 RPD cases.

Clinical utility of the forward-viewing echoendoscope in patients after pancreatoduodenectomy: A prospective study.

Background and Objectives: Endoscopic treatment of obstructive jaundice and pancreatitis due to hepaticojejunostomy (H-J), pancreatojejunostomy (P-J) strictures, and tumor recurrence after pancreatoduodenectomy (PD) is technically challenging. Treatment of P-J strictures results in poor outcomes. Although conventional EUS that has an oblique view is not suitable for such patients, forward-viewing EUS (FV-EUS) may become a useful option. This study aimed to evaluate the feasibility and efficacy of FV-EUS in patients who have undergone PD. Methods: Patients with PD who were scheduled to undergo diagnosis and treatment using FV-EUS for H-J or P-J lesions were enrolled in this single-center prospective study. After observation of the P-J and H-J using FV-EUS according to a predetermined protocol, treatment using FV-EUS was performed as needed. Results: A total of 30 patients were enrolled, and FV-EUS was used to observe P-J and H-J in 24 and 28 patients, respectively. The detection rates of P-J and H-J by endoscopy were 50% (12/24) and 96.4% (27/28), respectively, and by EUS were 70.8% (17/24) and 100% (28/28), respectively. Of these, P-J and H-J were found by endoscopy only after EUS observation in 3 and 1 patient, respectively. The success rates of endoscopic treatment using FV-EUS were 66.7% (2/3), 95.2% (20/21), and 25% (1/4) for benign P-J strictures, benign H-J strictures, and tumor recurrence, respectively. Conclusions: Endoscopic treatment using FV-EUS is feasible and effective for patients after PD. Moreover, FV-EUS increases the P-J lesion detection rate by adding EUS observation.

What is the optimal surgical approach for ductal adenocarcinoma of the pancreatic neck? - a retrospective cohort study.

BACKGROUND: The appropriate surgical approach for pancreatic ductal adenocarcinoma (PDAC) is determined by the tumor's relation to the porto-mesenteric axis. Although the extent and location of lymphadenectomy is dependent on the type of resection, a pancreatoduodenectomy (PD), distal pancreatectomy (DP), or total pancreatectomy (TP) are considered equivalent oncologic operations for pancreatic neck tumors. Therefore, we aimed to assess differences in histopathological and oncological outcomes for surgical approaches in the treatment of pancreatic neck tumors. METHODS: Patients with resected PDAC located in the pancreatic neck were identified from the National Cancer Database (2004-2020). Patients with metastatic disease were excluded. Furthermore, patients with 90-day mortality and R2-resections were excluded from the multivariable Cox-regression analysis. RESULTS: Among 846 patients, 58% underwent PD, 25% DP, and 17% TP with similar R0-resection rates (p = 0.722). Significant differences were observed in nodal positivity (PD:44%, DP:34%, TP:57%, p < 0.001) and mean-number of examined lymph nodes (PD:17.2 ± 10.4, DP:14.7 ± 10.5, TP:21.2 ± 11.0, p < 0.001). Furthermore, inadequate lymphadenectomy (< 12 nodes) was observed in 30%, 44%, and 19% of patients undergoing PD, DP, and TP, respectively (p < 0.001). Multivariable analysis yielded similar overall survival after DP (HR:0.83, 95%CI:0.63-1.11), while TP was associated with worse survival (HR:1.43, 95%CI:1.08-1.89) compared to PD. CONCLUSION: While R0-rates are similar amongst all approaches, DP is associated with inadequate lymphadenectomy which may result in understaging disease. However, this had no negative influence on survival. In the premise that an oncological resection of the pancreatic neck tumor is feasible with a partial pancreatectomy, no benefit is observed by performing a TP.

Survival benefit associated with screening of patients at elevated risk for pancreatic cancer.

BACKGROUND & OBJECTIVES: Screening for pancreatic cancer is recommended for individuals with a strong family history, certain genetic syndromes, or a neoplastic cyst of the pancreas. However, limited data supports a survival benefit attributable to screening these higher-risk individuals. METHODS: All patients enrolled in screening at a High-Risk Pancreatic Cancer Clinic (HRC) from July 2013 to June 2020 were identified from a prospectively maintained institutional database and compared to patients evaluated at a Surgical Oncology Clinic (SOC) at the same institution during the same period. Clinical outcomes of patients selected for surgical resection, particularly clinicopathologic stage and overall survival, were compared. RESULTS: Among 826 HRC patients followed for a median (IQR) of 2.3 (0.8-4.2) years, 128 were selected for surgical resection and compared to 402 SOC patients selected for resection. Overall survival was significantly longer among HRC patients (median survival: not reached vs. 2.6 years, p < 0.001). Among 31 HRC and 217 SOC patients with a diagnosis of pancreatic ductal adenocarcinoma (PDAC), the majority of HRC patients were diagnosed with stage 0 disease (carcinoma in situ), while the majority of SOC patients were diagnosed with stage II disease (p < 0.001). Overall survival after resection of invasive PDAC was also significantly longer among HRC patients compared to SOC patients (median survival 5.5 vs. 1.6 years, p = 0.002). CONCLUSION: Patients at increased risk for PDAC and followed with guideline-based screening exhibited downstaging of disease and improved survival from PDAC in comparison to patients who were not screened.

Anastomotic bleeding from invaginated pancreaticogastrostomy following pancreatoduodenectomy: incidence, risk factors, treatment and prevention.

BACKGROUND: Meta-analysis of 10 randomized prospective trials demonstrated a higher risk of postoperative bleeding from pancreaticogastrostomy (PG) compared with pancreatojejunostomy following pancreatoduodenectomy (PD). This study evaluated the incidence, risk factors, and treatment of anastomotic bleeding from invaginated PG. METHODS: We retrospectively evaluated all consecutive PDs performed between April 1, 2011 and December 31, 2022 using invaginated PG by the double purse-string technique. Multivariate analysis identified risk factors for anastomotic PG bleeding. RESULTS: During the study, 695 consecutive patients with a median age of 66 years underwent PD; the majority was performed for ductal pancreatic adenocarcinomas. Simultaneous vascular resections were performed in 328 patients. Postoperative mortality was 4.1%. Bleeding from PG occurred in 33(4.6%) patients at a median interval of 5 days (range, 1-14) from surgery, leading to reoperation in 21(63%). PG bleeding-related mortality was 9.0%. Multivariate analyses identified a soft pancreatic texture and Wirsung duct > 3 or ≤ 3 mm (Class C and D, respectively, of the ISGPS) (odds ratio [OR]: 2.17, 95% confidence interval [95% CI]: 1.38-3.44; P = 0.0009) and wrapping of the invaginated pancreas (OR: 0.37, 95% CI: 0.17-0.84; P = 0.01) as independent risk factors for PG bleeding. CONCLUSIONS: In a large volume setting, anastomotic bleeding from invaginated PG occurred in ~ 5% of patients and was associated with soft pancreatic parenchyma and small wirsung duct. The reduced rate of PG bleeding observed with wrapping of the invaginated pancreatic stump warrants further evaluation in a prospective randomized study.