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Background Perceived excess morbidity during the early learning curve of minimally-invasive pancreaticoduodenectomy (MIPD) has limited widespread adoption. It was hypothesized that robot-assisted reconstruction (RA) after MIPD allows anastomotic outcomes equivalent to open pancreaticoduodenectomy (PD). Methods Intent to treat analysis of centrally audited data accrued during early adoption of RA-MIPD at five centers. Results CUSUM analysis of operating times at each center identified 92 RA-MIPD during the early learning curve. Mean age was 65 ± 12 years with body mass index 25.8 ± 5.0. Surgical indications included malignant (60%) and premalignant (38%) lesions. Median operating time was 504 min (interquartile range 133) with 242 ml median estimated blood loss (IQR 398) and twelve (13%) conversions to open PD. Major complication rate (Clavien-Dindo III/IV) was 24% with 2 (2.2%) deaths and ten (10.9%) reoperations. Nine (9.9%) clinically significant pancreatic fistulae were observed (4 grade B; 5 grade C). Margin negative resection rate for malignancy was 90% (75% for PDA) with mean harvest of 16 ± 8 lymph nodes. Conclusions These multicenter data during the early learning curve for RA-MIPD do not demonstrate excess anastomotic morbidity compared to open. Further studies are required to determine whether surgeon proficiency and evolving technique improve anastomotic outcomes compared to open.

BackgroundData have indicated that the lymph node ratio (LNR) may be a better prognostic indicator than lymph node status in pancreatic cancer.ObjectivesTo analyse the value of the LNR in patients undergoing resection for periampullary carcinomas.MethodsA cut off value of 0.2 was assigned to the LNR in accordance with published studies. The impact of histopathological factors including a LNR was analysed using Kaplan–Meier and Cox regression methods.ResultsIn total, 551 patients undergoing a resection (January 2000 to December 2010) were analysed. The median lymph node yield was 15, and 198 (34%) patients had a LNR > 0.2. In patients with a LNR of > 0.2, the median overall survival (OS) was 18 versus 33 months in patients with an LNR < 0.2 (P < 0.001). Univariate analysis demonstrated a LNR > 0.2, T and N stage, vascular or perineural invasion, grade and resection margin status to be significantly associated with OS. On multivariate analysis, only a LNR > 0.2, vascular or perineural invasion and margin positivity remained significant. In N1 disease, a LNR was able to distinguish survival in patients with a similar lymph node burden, and correlated with more aggressive tumour pathological variables.ConclusionA LNR > 0.2, and not lymph note status, is an independent prognostic factor for OS indicating the LNR should be utilized in outcome stratification.

BackgroundThe management of asymptomatic pancreatic cysts is controversial and indications for excision are based on pathology and natural history.ObjectivesThis study aimed to examine outcomes of asymptomatic lesions using a protocol based on size and cyst fluid analysis.MethodsAsymptomatic cysts were identified from a prospectively maintained database. Sequential cross‐sectional imaging studies were assessed, and results of endoscopic ultrasound‐guided aspiration were co‐analysed.ResultsA total of 338 asymptomatic patients underwent evaluation. Overall, 84 cysts were 12 months post‐presentation in six (9.5%) patients. A total of 70.6% of resected specimens were identified as malignancies or mucinous lesions.conclusionsAsymptomatic cysts of

BackgroundHepato-pancreatico-biliary (HPB) fellowship training has risen in popularity in recent years and hence large numbers of graduating fellows enter the workforce each year. Studies have proposed that the increase in HPB-trained surgeons will outgrow demand in the USA. This study shows that the need for HPB-trained surgeons refers not to the meeting of demand in terms of case volume, but to improving patient access to care.MethodsThe National Inpatient Sample (NIS) database for the years 2005–2011 was queried for CPT codes relating to pancreatic, liver and biliary surgical cases. These numbered 6627 in 2005 and increased to 8515 in 2011. Cases were then mapped to corresponding states. The number of procedures in an individual state was divided by the total number of procedures to give a ratio for each state. A similar ratio was calculated for the population of each state to the national population. These ratios were combined to give a ratio by state of observed to expected HPB surgical cases.ResultsOf the 46 states that participate in the NIS, only 18 achieved ratios of observed to expected cases of >1. In the remaining 28 states, the number of procedures was lower than that expected according to each state's population.ConclusionsThe majority of the USA is underserved in terms of HPB surgery. Given the growing number of HPB-trained physicians entering the job market, this sector should focus on bringing understanding and management of complex disease to areas of the country that are currently in need.