Perioperative factors associated with survival following surgery for pancreatic cancer - a nationwide analysis of 473 cases from Denmark.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal cancers worldwide, with an overall 5-year survival rate of only 5%. The effect of perioperative treatment factors including duration of surgery, blood transfusions as well as choice of anesthesia and analgesia techniques on overall survival (OS) following pancreatic resections for PDAC, is currently not well known. We hypothesized that these perioperative factors might be associated with OS after pancreatic resections for PDAC. METHODS: This is a retrospective study from a nationwide cohort of patients who underwent surgery for PDAC in Denmark from 2011 to 2020. Kaplan-Meier 1, 2 and 5-year survival estimates were 73%, 49% and 22%, respectively. Data were obtained by joining the national Danish Pancreatic Cancer Database (DPCD) and the Danish Anaesthesia Database (DAD). Associations between the primary endpoint (OS) and perioperative factors including duration of surgery, type of anesthesia (intravenous, inhalation or mixed), use of epidural analgesia and perioperative blood transfusions were assessed using Hazard Ratios (HRs). These were calculated by Cox regression, controlling for relevant confounders identified through an assessment of the current literature. These included demographics, comorbidities, perioperative information, pre and postoperative chemotherapy, tumor staging and free resection margins. RESULTS: Overall, data from 473 resected PDAC patients were available. Multivariate Cox regression indicated that perioperative blood transfusions were associated with shorter OS (HR 2.53, p = 0.005), with survival estimates of 8.8% in transfused vs. 28.0% in non-transfused patients at 72 months after surgery. No statistically significant associations were identified for the duration of surgery or anesthesia/analgesia techniques. CONCLUSION: In this study, the use of perioperative blood transfusions was associated with shorter OS.

The results of surgery for renal cell carcinoma metastases of the pancreas.

BACKGROUND: Pancreatic metastases from renal cell carcinoma (RCC) are rare. This study evaluated the surgical pathology and outcomes after resection of RCC metastases to the pancreas. MATERIAL AND METHODS: A retrospective review of from 1 January 2011 to 31 December 2021, of patients who underwent pancreatic surgery for metastases from RCC. Data were retrieved from a prospectively managed database and patient demographics, comorbidities, pathology, perioperative outcomes, and overall survival were analyzed. Median overall survival (OS) and disease-free survival (DFS) were estimated by the Kaplan-Meier method. RESULTS: There were 25 patients (17 males, 8 females, median age 66 range 51 - 79 year), all with metachronous metastases. Median time from resection of the primary to operation for pancreatic RCC was 95.6 (12.0 - 309.7) months. Twenty-four patients were operated with intended cure (four pancreaticoduodenectomies, three total pancreatectomies, 17 distal pancreatectomies) and one patient had abortive surgery due to dissemination. Postoperative surgical complications occurred in nine patients (36%), and one patient died during hospital stay. Eight patients (33.3%) developed exocrine and/or endocrine insufficiency after pancreatic resection. Fifteen patients (60%) had recurrence 21.7 (4.9 - 61.6) months after pancreatic operation. Five patients (25%) died from RCC during follow-up 46.3 (25.6 - 134.8) months after pancreatic resection. Five-year OS and DFS were83.6% and 32.3%, respectively. Median OS after pancreatic surgery was 134.8 months, independent of resection of previous extrapancreatic metastases. CONCLUSIONS: Pancreatic resection for metastases from RCC offers favorable prognosis with a curative potential and should be considered a valuable treatment option even in the era of novel targeted treatment.

Empagliflozin Normalizes Fasting Hyperglycemia and Improves Postprandial Glucose Tolerance in Totally Pancreatectomized Patients: A Randomized, Double-Blind, Placebo-Controlled Crossover Study.

OBJECTIVE: Insulin remains the only glucose-lowering treatment modality recommended for totally pancreatectomized patients. We investigated the effects of the sodium-glucose cotransporter 2 inhibitor empagliflozin on fasting and postprandial glucose concentrations in pancreatectomized patients and matched healthy control participants. RESEARCH DESIGN AND METHODS: In a randomized, double-blind, placebo-controlled crossover study, 10 pancreatectomized patients and 10 matched control participants underwent two 3-h liquid mixed meal tests preceded by two doses of 25 mg empagliflozin (administered the night before and in the morning of the meal test) or placebo, respectively. Basal insulin was administered as usual, but bolus insulin was omitted before the meal test during experimental days. RESULTS: Compared with placebo, empagliflozin lowered fasting plasma glucose (5.0 ± 0.4 vs. 7.9 ± 0.9 mmol/L [mean ± SEM], P = 0.007) and postprandial plasma glucose excursions as assessed by baseline-subtracted area under the curve (1,080 [733; 1,231] vs. 1,169 [1,036; 1,417] pmol/L × min [median (25th and 75th percentiles)], P = 0.014) in the pancreatectomized patients. In the control participants, empagliflozin lowered fasting plasma glucose compared with placebo (5.1 ± 0.1 vs. 5.5 ± 0.1 mmol/L, P = 0.008) without affecting postprandial glucose excursions significantly. The pancreatomy group exhibited greater postprandial glucagon excursions compared with the control group on both experimental days (P ≤ 0.015); no within-group differences between days were observed. CONCLUSIONS: Empagliflozin administered the day before and immediately before a standardized liquid mixed meal test normalized fasting hyperglycemia and improved postprandial glucose tolerance in pancreatectomized patients.

Impact of para aortic lymph node removal on survival following resection for pancreatic adenocarcinoma.

INTRODUCTION: For PDAC patients undergoing resection, it remains unclear whether metastases to the paraaortic lymph nodes (PALN+) have any prognostic significance and whether metastases should lead to the operation not being carried out. Our hypothesis is that PALN + status would be associated with short overall survival (OS) compared with PALN-, but longer OS compared with patients undergoing surgical exploration only (EXP). METHODS: Patients with registered PALN removal from the nationwide Danish Pancreatic Cancer Database (DPCD) from May 1st 2011 to December 31st 2020 were assessed. A cohort of PDAC patients who only had explorative laparotomy due to non-resectable tumors were also included (EXP group). Survival analysis between groups were performed with cox-regression in a multivariate approach including relevant confounders. RESULTS: A total of 1758 patients were assessed, including 424 (24.1%) patients who only underwent explorative surgery leaving 1334 (75.8%) patients for further assessment. Of these 158 patients (11.8%) had selective PALN removal, of whom 19 patients (12.0%) had PALN+. Survival analyses indicated that explorative surgery was associated with significantly shorter OS compared with resection and PALN + status (Hazard Ratio 2.36, p < 0.001). No difference between PALN + and PALN- status could be demonstrated in resected patients after controlling for confounders. CONCLUSION: PALN + status in patients undergoing resection offer improved survival compared with EXP. PALN + should not be seen as a contraindication for curative intended resection.

The results of pancreatic surgery in Inuit patients from Greenland 1999-2022.

The study evaluates the outcome after surgery for pancreatic and periampullary tumors in Greenlandic Inuit with overall survival (OS) of pancreatic ductal adenocarcinoma (PDAC) as secondary outcome. Results were compared with Danish patients with an identical tumor stage and age operated at the same hospital during the same period from 31. January 1999 to 31. January 2021. Follow up was minimum one year. Preoperative health data shoved a higher rate of smoking among Greenlandic patients, but a lower preoperative comorbidity than in Danish patients. Patients from Greenland had a lower resection rate and a higher rate of palliative operations. Postoperative complications and in-hospital mortality were not significantly different. Adjuvant oncologic treatment was well accepted by Greenlandic patients but less common in a palliative setting than in Danish patients. The one, two, and five-year survival in Greenlandic and Danish patients after radical operation for PDAC was 54.4% vs. 74.6%, 23.4% vs. 48.6%, and 0.0% vs. 23.4%, respectively. The overall survival with non-resectable PDAC was 5.9 and 8.8 months, respectively. It is concluded that although patients from Greenland have the same access to specialized treatment, the outcome after treatment for pancreatic and periampullary cancer is less favorable than in Danish patients.

Major vascular and pancreatic penetrating trauma in patient with pre-existing MALS.

We report a case regarding a 24-year-old male with severe intraabdominal complex vascular lesions involving the superior mesenteric vein (SMV), portal vein (PV), inferior vena cava (IVC), the Common Hepatic and Gastroduodenal arteries (CHA and GDA) in combination with a total transection of the pancreatic neck following a single penetrating trauma to the upper abdomen. The management of the splanchnic vascular lesions were further complicated by the patient having pre-existing vascular condition known as Median Arcuate Ligament Syndrome (MALS). The MALS aspect makes this case unique and interesting to all trauma surgeons. Furthermore, this case report also reflects on the management of severe pancreatic trauma in the setting of the aforementioned vascular lesions.

Targeted next-generation sequencing of EUS-guided through-the-needle-biopsy sampling from pancreatic cystic lesions.

BACKGROUND AND AIMS: Recent advances have introduced molecular subtyping of pancreatic cystic lesions (PCLs) as a possible amendment to the diagnostic algorithm. The study evaluated the feasibility and diagnostic accuracy of molecular analysis and subtyping of PCLs using the recently introduced EUS-guided through-the-needle-biopsy (TTNB) sampling. METHODS: We prospectively included 101 patients in the study who presented with PCLs >15 mm in the largest cross-section. EUS-guided TTNB samples were obtained by a micro-biopsy forceps introduced through a 19-gauge needle. The TTNB samples were analyzed by next-generation sequencing (NGS) for point mutations in tumor suppressors and oncogenes using a 51-gene customized hotspot panel. Sensitivity and specificity were calculated with the histologic diagnosis as reference. RESULTS: After initial microscopic evaluation of the samples, 91 patients had residual TTNB samples available for NGS. Of these, 49 harbored mutations, most frequently in KRAS and GNAS, reflecting an excess frequency of intraductal papillary mucinous neoplasms (IPMNs) in the study population. A sensitivity and specificity of 83.7% (95% confidence interval [CI], 70.3-92.7) and 81.8% (95% CI, 48.2-97.7), respectively, were demonstrated for the diagnosis of a mucinous cyst and 87.2% (95% CI, 74.2-95.2) and 84.6% (95% CI, 54.5-98.1) for the diagnosis of an IPMN. CONCLUSIONS: Thus, molecular analysis of TTNB samples by NGS has high sensitivity and specificity for diagnosing mucinous cysts and IPMNs. Although the procedure comes with a risk of adverse events of 9.9%, TTNB samples are a robust alternative to cyst fluid for a combined histologic and molecular diagnosis of PCLs. (Clinical trial registration number: NCT03578445.).

Relieving the bile ducts prior to pancreatoduodenectomy - A retrospective cohort study.

Introduction: Obstructive jaundice is a common problem in pancreatic and periampullary tumors, but preoperative biliary drainage in patients with hyperbilirubinemia is still controversial. This study aimed to assess the risk of complications after preoperative drainage of biliary obstruction in patients who underwent pancreaticoduodenectomy. Method: A retrospective cohort study of all patients who underwent pancreaticoduodenectomy from January 1st, 2015 to September 30th, 2021. Patients who had preoperative bile duct drainage were compared to patients without intervention. Type of interventions, complications, and outcomes after surgery were compared using univariate and multivariate analysis. Results: Of 722 patients who underwent pancreatoduodenectomy, 389 patients had preoperative drainage of the bile ducts by ERC or PTC. There was an incidence of 27% drainage-related complications, all categorized as minor (Clavien-Dindo <3) and mainly related to PTC-aided drainage. After pancreaticoduodenectomy, 23% of patients who had a preoperative biliary drain, had minor complications. Patients without biliary drainage had a higher risk of a complicated postoperative course (p = 0.001) and had a higher 30-day (p = 0.002) and 90-day mortality (p = 0.025). Conclusion: Our study found preoperative bile duct drainage to be a safe procedure without severe complications. Patients undergoing preoperative bile duct drainage had fewer post-pancreatoduodenectomy complications and lower mortality.

Pancreatic surgery during the COVID-19 pandemic 2020-2021: an observational cohort study from a third level referral center.

BACKGROUND: During the COVID pandemic there has been limited access to elective surgery including oncologic surgery in several countries world-wide. The aim of this study was to investigate if there was any lockdown effect on pancreatic surgery with special focus on malignant pancreatic and periampullary tumours. METHODS: Patients who underwent pancreatic surgery during the two Danish lockdown periods from 11. March 2020 and the following 12 months were compared with patients who were operated the preceding 3 years. Data on patients' characteristics, waiting time, operations, and clinical outcomes were evaluated. RESULTS: During lockdown and the previous three years the annual number of resections were 242, 232, 253, and 254, respectively (p = 0.851). Although the numbers were not significantly different, there were fluctuations in operations and waiting time during the lockdown. During the second outbreak of COVID October 2020 to March 2021 the overall median waiting time increased to 33 days (quartiles 26;39) compared to 23 (17;33) days during the first outbreak from March to May 2020 (p = 0.019). The same difference was seen for patients with malignant tumours, 30 (23;36) vs. 22 (18;30) months (p = 0.001). However, the fluctuations and waiting time during lockdown was like the preceding three years. Neither 30- nor 90-days mortality, length of stay, number of extended operations, and complications and tumour stage were significantly different from previous years. CONCLUSIONS: There were significant fluctuations in waiting time for operations during the lockdown, but these variations were not different from the preceding three years, wherefore other explanations than an impact from COVID are conceivable.

Long-term results after resection of primary duodenal adenocarcinoma: A retrospective cohort study.

BACKGROUND: Radical resection of duodenal adenocarcinoma (DA) offers the possibility of cure. The outcome after operation and adjuvant therapy is mainly based on small numbers due to the low incidence of the disease. We examined the long-term outcome after surgical treatment of DA. MATERIAL AND METHODS: This was a retrospective cohort study including all patients undergoing curatively intended resection for histologically confirmed DA at a single University hospital. Long-term survival was examined by the Kaplan-Meier method and compared with the log-rank test. Multivariable Cox proportional hazards regression analysis was applied to adjust for confounding. RESULTS: A total of 96 patients were included. The median follow-up was 3.7 years (IQR 2.9-4.3), during which 18 patients (18.5%) had recurrence and 35 (36.5%) patients had died. The 3- and 5-year overall survival was 66.3% (55.6-76.9%) and 58.2% (46.2-70.2%), respectively. In the multivariable analysis, adjuvant therapy was associated with decreased mortality (HR 0.29, CI 0.11-0.76, P = 0.011) whereas positive lymph node ratio >0.20 was associated with increased mortality. CONCLUSION: Radical operation for DA has a median overall 5-year-survival of more than 50%. The indication for adjuvant chemotherapy remains to be addressed.

Long-Term Outcomes of Venous Resections in Pancreatic Ductal Adenocarcinoma Patients: A Nationwide Cohort Study.

To investigate whether pancreatic resections (PR) for pancreatic ductal adenocarcinoma (PDAC) is associated with worse survival when resection of the superior mesenteric vein/portal vein (SMV/PV) is required. Background: PR for PDAC with resection of the superior mesenteric vein/portal vein (SMV/PV, PR+V resection) may be associated with inferior overall survival (OS) compared with PR without the need for SMV/PV resection (PR-V). We hypothesized that PR+V results in lower OS compared with PR-V. Method: Retrospective study using data from the nationwide Danish Pancreatic Cancer Database from 2011 to 2020. Data on patients who underwent PR for PDAC were extracted. A group of PR patients found nonresectable on exploratory laparotomy (EXP) was also included. OS was assessed using Kaplan-Meier and Cox proportional hazards models adjusting for confounders (age, sex, R-resection level, chemotherapy, comorbidities, histology T and N classification, procedure subtype as well as tumor distance to the SMV/PV). Results: Overall, 2403 patients were identified. Six hundred two underwent exploration only (EXP group), whereas 412 underwent pancreatic resection with (PR+V group) and 1389 (PR-V) without SMV/PV resection. Five-year OS for the PR+V group was lower (20% vs 30%) compared with PR-V, although multivariate Cox proportional hazards modeling could not associate PR+V status with OS (Hazard ratio 1.11, P = 0.408). Conclusion: When correcting for confounders, PR+V was not associated with lower OS compared with PR-V.

The diagnostic value of C-reactive protein for predicting pancreatic fistula following pancreatoduodenectomy.

INTRODUCTION: Pancreaticoduodenectomy is the preferred treatment of neoplasms in the pancreas and duodenum. Postoperative pancreatic fistula is a critical complication. A potential predictive marker is C-reactive protein. This retrospective study examined the predictive value of C-reactive protein as a marker for development of postoperative pancreatic fistulas. METHODS: All patients who had a pancreaticoduodenectomy from 1 January 2015 to 31 December 2019, were included. Levels of the biomarker and linear trajectory were determined for postoperative days one to four. Univariate analysis was used to identify predictive variables for a postoperative pancreatic fistula. Receiver operating characteristics curves, specificity, and sensitivity were calculated. RESULTS: Five hundred and fifty-two patients underwent pancreaticoduodenectomy. C-reactive protein level greater than 121.5mg/L on the third postoperative day and an increase in C-reactive protein level between the first and fourth postoperative days, greater than 21.7mg/L, seemed to be reliable predictors. For Grade C postoperative pancreatic fistulas, increases in C-reactive protein, greater than 40.6ml/L the first four postoperative days, had a sensitivity of 100%. White blood cell count did not have similar reliability in predicting postoperative pancreatic fistulas. CONCLUSION: Our findings indicate that small rises in C-reactive protein during the first postoperative days after pancreaticoduodenectomy are associated with an increased risk of developing postoperative pancreatic fistula.

Biliary Leakage Following Pancreatoduodenectomy: Experience from a High-Volume Center.

Purpose: Hepaticojejunostomy leak and bile fistula after pancreaticoduodenectomy (PD) are less frequent than pancreatic leaks. Patients with biliary fistula (BF) have an increased risk of serious complications and an extended hospital stay. This study has investigated the occurrence and outcome of BF. Methods: All patients who underwent a PD from January 1st, 2015 to December 31st, 2019 were included. The significance of multiple risk factors was examined. Univariate analysis was used to identify predictive variables for postoperative BF. Results: Of the 552 patients who underwent PD, 38 patients (6.7%) developed a BF. Patients with nonmalignant diagnoses and malignancies without bile duct obstruction had a greater risk of developing BF. BF did not increase the mortality, though most patients had complications, including surgical site infections, intraabdominal abscesses, and an extended hospital stay. Conclusion: BF after PD leads to an increased risk of subsequent complications and an extended hospital stay but does not increase mortality. Patients with nonmalignant diagnoses and malignancies without bile duct obstruction have an increased risk of BF.

Glycemic Control and Variability of Diabetes Secondary to Total Pancreatectomy Assessed by Continuous Glucose Monitoring.

CONTEXT: The extent of the glycemic variability in diabetes secondary to total pancreatectomy is not fully understood. OBJECTIVE: To evaluate glycemic variability in totally pancreatectomized (PX) patients and compare it to glycemic variability in hemoglobin A1c (HbA1c)-matched patients with long-standing type 1 diabetes (T1D). DESIGN: A case-control study was performed. SETTING: Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark. PATIENTS OR OTHER PARTICIPANTS: Ten PX patients (mean [SEM]: age 64.3 [9.8] years; body mass index (BMI) 34.4 [5.0] kg/m2; duration of diabetes 3 [2.8] years), 10 HbA1c-matched patients with T1D (63.9 [8.6] years; 24.6 [3.1] kg/m2; 22 [4] years), and 10 gender-, age-, and BMI-matched healthy controls. All patients were managed on multiple daily injections of insulin. INTERVENTION: Continuous glucose monitoring (CGM) (Medtronic MiniMed iPro 2) during 12 consecutive days. MAIN OUTCOME MEASURES: Glycemic variability. RESULTS: HbA1c levels were similar in the PX group and the T1D group. The PX group had greater continuous overall net glycemic action per 60 minutes (CONGA60 min) compared with the T1D group (mean [SEM]: 9.5 [0.3] vs 8.3 [0.2] mmol/L, P < 0.003) and mean plasma glucose values were higher in the PX group (10.6 [0.9] vs 9.0 [0.9] mmol/L, P < 0.001), whereas coefficient of variation for plasma glucose and standard deviation of mean plasma glucose, respectively, were similar in the 2 groups. Time spent below range was not different between the PX and the T1D group (2.3 [0.8] vs 4.5 [0.8]%, P = 0.065), whereas time spent above range was higher in the PX group (51.4 [3.3] vs 37.6 [1.9]%, P < 0.001). CONCLUSIONS: CGM-assessed glycemic variability showed higher CONGA60 min and time spent above range in our PX patients compared with HbA1c-matched T1D patients. This study is registered at www.ClinicalTrials.gov (NCT02944110).

Clinical impact of endoscopic ultrasound-guided through-the-needle microbiopsy in patients with pancreatic cysts.

BACKGROUND: The limited data on the utility of endoscopic ultrasound (EUS)-guided through-the-needle biopsies (TTNBs) in patients with pancreatic cystic lesions (PCLs) originate mainly from retrospective studies. Our aim was to determine the clinical impact of TTNBs, their added diagnostic value, and the adverse event rate in a prospective setting. METHODS: This was a prospective, single-center, open-label controlled study. Between February 2018 and August 2019, consecutive patients presenting with a PCL of 15 mm or more and referred for EUS were included. Primary outcome was a change in clinical management of PCLs following TTNB compared with cross-sectional imaging and cytology. Adverse events were defined according to the ASGE lexicon. RESULTS: 101 patients were included. TTNBs led to a change in clinical management in 11.9 % of cases (n = 12). Of these, 10 had serous cysts and surveillance was discontinued, while one of the remaining two cases underwent surgery following diagnosis of a mucinous cystic neoplasm. The diagnostic yield of TTNBs for a specific cyst diagnosis was higher compared with FNA cytology (69.3 % vs. 20.8 %, respectively; P < 0.001). The adverse event rate was 9.9 % (n = 10; 95 % confidence interval 5.4 % - 17.3 %), with the most common event being acute pancreatitis (n = 9). Four of the observed adverse events were severe, including one fatal outcome. CONCLUSIONS: TTNBs resulted in a change of clinical management in about one in every 10 patients; however, the associated adverse event risk was substantial. Further studies are warranted to elucidate in which subgroups of patients the clinical benefit outweighs the risks.

Spontaneous intestinal bleeding due to pseudoaneurism of the gastroduodenal artery: case report of a rare complication to median arcuate ligament syndrome.

Median arcuate ligament syndrome (MALS) is the compression of the celiac artery (CA) by the median arcuate ligament. MALS can cause pseudoaneurysm of the gastroduodenal artery, which can lead to fatal bleeding. A 40-year-old male with no prior medical history presented with symptoms of upper gastrointestinal hemorrhage (UGIH). Severe duodenal bleeding was confirmed although endoscopic hemostasis was impossible and final hemostasis was achieved following a subsequent open duodenotomy. A postoperative computed tomographic angiography (CTA) visualized a significant CA stenosis, post-stenotic dilatation and an aneurysm on a jejunal branch artery. The patient underwent coiling of the gastroduodenal artery, gastroepiploic artery and two pancreaticoduodenal arterial branches. The patient was diagnosed with MALS and 6 months later underwent open resection of the median arcuate ligament. MALS should be considered as a rare cause of upper gastrointestinal bleeding. The literature and proposed treatments are discussed.

Diagnostic performance of current guidelines and postoperative outcome following surgical treatment of cystic pancreatic lesions - a 10-year single center experience.

OBJECTIVE: Pancreatic cystic lesions (PCLs) are diagnostically challenging and there are currently several different guidelines. The aim of this study was to compare diagnostic performance of the most widely utilized International Association of Pancreatology (IAP) guidelines and the recent evidence-based European guidelines and to report on postoperative outcomes following surgical treatment of PCLs. METHODS: This is a retrospective single-center study of patients undergoing surgery due to a PCL between 2010 and 2019. Primary outcome was a comparison of diagnostic performance between IAP and European guidelines, measured in area under the receiver operating characteristic curve (AUC). Other outcomes included diagnostic performance of different risk features, 30-day postoperative mortality and major morbidity, final diagnosis, and overall survival. RESULTS: We identified 137 patients, three of whom did not undergo curative surgery due to metastatic disease. Overall, there was no difference in the performance of the two guidelines with AUC values ranging from 0.572-0.610 and 0.607-0.621 for IAP and European guidelines respectively. Postoperative 30-day mortality and major morbidity were 0% (95% CI 0.0-2.7%) and 37.3% (95% CI 29.1-46.1%), respectively. More than half of the resected lesions (52.6%) were low-grade dysplastic or non-neoplastic. CONCLUSIONS: Overall, the IAP and the European guidelines performed equally, although European guidelines had a slightly higher mean specificity. Pancreatic surgery is associated with high major morbidity, and there is a need for new diagnostic tools and strategies in order to decrease the amount of overtreatment in patients with PCL.

[Minimally invasive surgery for malignant diseases in pancreas].

Unlike most other abdominal procedures, pancreatic resection for malignant tumours is still predominantly performed as open surgery. However, recent published randomised trials suggest that a laparoscopic approach is safe and may offer advantages in the early postoperative period. Likewise, early reports of robot-assisted pancreatic resection suggest advantages. This reveiw describes the current status of minimally invasive pancreatic surgery for malignant tumours, including both laparoscopic and robot-assisted approaches for pancreaticoduodenectomy and distal pancreatectomy.