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Background/Purpose: The eighth edition of the AJCC staging system introduced a shift in the staging of distal bile duct cancer (DBC), emphasizing the depth of invasion over adjacent organ invasion. This study aimed to evaluate the clinical impact of pancreatic invasion in pT1‐stage DBC and identify prognostic factors for long‐term survival. Methods: This multicenter retrospective analysis encompassed DBC patients who underwent pancreaticoduodenectomy between 2009 and 2019 in six Korean tertiary centers, specifically those with final pathology confirming AJCC eighth edition T1 stage and intrapancreatic bile duct tumor origin. Primary endpoints were five‐year recurrence‐free survival (RFS) and overall survival (OS). Secondary objectives included the identification of prognostic determinants. Results: This study involved 287 patients, comprising 190 without and 97 with pancreatic invasion. Pancreatic invasion did not significantly influence five‐year OS and RFS rates (OS: without pancreatic invasion 69.9% vs. with pancreatic invasion 54.1%, p =.25; RFS: 56.3% vs. 55.4%, p =.97). Multivariate analysis highlighted male gender, age, lymphovascular invasion, and N stage as significant OS determinants. Notably, male gender, ampulla of Vater invasion, lymphovascular invasion, and N1 stage were also associated with RFS. Conclusions: In pT1 DBC, pancreatic invasion demonstrates no substantial impact on long‐term prognosis, in accordance with the depth‐based paradigm of the eighth edition AJCC staging system. The prognostic factors influencing OS were identified as male gender, age, lymphovascular invasion, and nodal metastasis. [ABSTRACT FROM AUTHOR]

Background: Several guidelines exist for minimally invasive pancreatoduodenectomy (MIPD) regarding its prerequisites and learning curve. However, these guidelines are based on the experience of the pioneers of MIPD; minimal data exist on the experience of the next generation of surgeons. The aim of this study was to compare the two surgeon types (veteran and junior) for MIPD in terms of immediate postoperative outcomes. Methods: The postoperative outcomes of 22 patients who underwent robot‐assisted pancreatoduodenectomy (RAPD) by a junior surgeon from July 2021 to December 2022 were retrospectively reviewed. The outcomes were compared with the initial postoperative outcomes and the contemporary postoperative outcomes of RAPD by a veteran surgeon. Results: In comparing the initial outcomes between the two surgeon types, the veteran surgeons showed a shorter operation time (junior surgeon vs. veteran surgeon: 606 ± 89 vs. 467 ± 77 min, p < 0.001). However, there was no significant difference in terms of postoperative outcomes, such as blood loss (300 [200–600] ml. vs. 200 [100–500] ml, p = 0.208), major complications (≥CDC IIIa: 4 (18.2%) vs. 4 (18.2%), p = 1.000), postoperative pancreatic fistula (POPF; ≥ISGPF Grade B: 2 (9.1%) vs. 3 (13.6%), p > 0.999), and length of hospital stay (18.0 ± 8.9 days vs. 18.3 ± 7.9 days, p = 0.915), between the two surgeon types. In addition, in a comparison of the contemporary outcomes, there was no significant difference in terms of postoperative outcome (complications: 4 (18.2%) vs 11 (11.1%), p = 0.580; POPF: 2 (9.1%) vs. 3 (3.0%), p = 0.484; length of hospital stay: 18.0 ± 8.9 vs. 15.0 ± 6.5 days, p = 0.065). Conclusion: The initial outcomes of MIPD by a well‐trained junior surgeon were found to be comparable to those of MIPD by a veteran surgeon. [ABSTRACT FROM AUTHOR]

Background/Purpose: Little is known about the features of T1 pancreatic ductal adenocarcinoma (PDAC) and its definition in the eighth edition of the American Joint Committee on Cancer (AJCC) staging system needs validation. The aims were to analyze the clinicopathologic features of T1 PDAC and investigate the validity of its definition. Method: Data from 1506 patients with confirmed T1 PDAC between 2000 and 2019 were collected and analyzed. The results were validated using 3092 T1 PDAC patients from the Surveillance, Epidemiology, and End Results (SEER) database. Results: The median survival duration of patients was 50 months, and the 5‐year survival rate was 45.1%. R0 resection was unachievable in 10.0% of patients, the nodal metastasis rate was 40.0%, and recurrence occurred in 55.2%. The current T1 subcategorization was not feasible for PDAC, tumors with extrapancreatic extension (72.8%) had worse outcomes than those without extrapancreatic extension (median survival 107 vs. 39 months, p <.001). Extrapancreatic extension was an independent prognostic factor whereas the current T1 subcategorization was not. The results of this study were reproducible with data from the SEER database. Conclusion: Despite its small size, T1 PDAC displayed aggressive behavior warranting active local and systemic treatment. The subcategorization by the eighth edition of the AJCC staging system was not adequate for PDAC, and better subcategorization methods need to be explored. In addition, the role of extrapancreatic extension in the staging system should be reconsidered. [ABSTRACT FROM AUTHOR]

Background: Carbohydrate antigen (CA) 19–9 is a known pancreatic cancer (PC) biomarker, but is not commonly used for general screening due to its low sensitivity and specificity. This study aimed to develop a serum metabolites‐based diagnostic calculator for detecting PC with high accuracy. Methods: A targeted quantitative approach of direct flow injection‐tandem mass spectrometry combined with liquid chromatography–tandem mass spectrometry was employed for metabolomic analysis of serum samples using an Absolute IDQ™ p180 kit. Integrated metabolomic analysis was performed on 241 pooled or individual serum samples collected from healthy donors and patients from nine disease groups, including chronic pancreatitis, PC, other cancers, and benign diseases. Orthogonal partial least squares discriminant analysis (OPLS‐DA) based on characteristics of 116 serum metabolites distinguished patients with PC from those with other diseases. Sparse partial least squares discriminant analysis (SPLS‐DA) was also performed, incorporating simultaneous dimension reduction and variable selection. Predictive performance between discrimination models was compared using a 2‐by‐2 contingency table of predicted probabilities obtained from the models and actual diagnoses. Results: Predictive values obtained through OPLS‐DA for accuracy, sensitivity, specificity, balanced accuracy, and area under the receiver operating characteristic curve (AUC) were 0.9825, 0.9916, 0.9870, 0.9866, and 0.9870, respectively. The number of metabolite candidates was narrowed to 76 for SPLS‐DA. The SPLS‐DA‐obtained predictive values for accuracy, sensitivity, specificity, balanced accuracy, and AUC were 0.9773, 0.9649, 0.9832, 0.9741, and 0.9741, respectively. Conclusions: We successfully developed a 76 metabolome‐based diagnostic panel for detecting PC that demonstrated high diagnostic performance in differentiating PC from other diseases. [ABSTRACT FROM AUTHOR]

Background/Purpose: The current study aimed to develop a prediction model using a multi‐marker panel as a diagnostic screening tool for pancreatic ductal adenocarcinoma. Methods: Multi‐center cohort of 1991 blood samples were collected from January 2011 to September 2019, of which 609 were normal, 145 were other cancer (colorectal, thyroid, and breast cancer), 314 were pancreatic benign disease, and 923 were pancreatic ductal adenocarcinoma. The automated multi‐biomarker Enzyme‐Linked Immunosorbent Assay kit was developed using three potential biomarkers: LRG1, TTR, and CA 19‐9. Using a logistic regression model on a training data set, the predicted values for pancreatic ductal adenocarcinoma were obtained, and the result was classification into one of the three risk groups: low, intermediate, and high. The five covariates used to create the model were sex, age, and three biomarkers. Results: Participants were categorized into four groups as normal (n = 609), other cancer (n = 145), pancreatic benign disease (n = 314), and pancreatic ductal adenocarcinoma (n = 923). The normal, other cancer, and pancreatic benign disease groups were clubbed into the non‐pancreatic ductal adenocarcinoma group (n = 1068). The positive and negative predictive value, sensitivity, and specificity were 94.12, 90.40, 93.81, and 90.86, respectively. Conclusions: This study demonstrates a significant diagnostic performance of the multi‐marker panel in distinguishing pancreatic ductal adenocarcinoma from normal and benign pancreatic disease states, as well as patients with other cancers. [ABSTRACT FROM AUTHOR]

We investigated the anticancer effect of the aptamer‐conjugated gemcitabine‐loaded atelocollagen patch in a pancreatic cancer patient–derived xenograft (PDX) model to propose a future potential adjuvant surgical strategy during curative pancreatic resection for pancreatic cancer. A pancreatic cancer PDX model was established. Animals were grouped randomly into a no‐treatment control group; treatment group treated with intraperitoneal gemcitabine injection (IP‐GEM) or aptamer‐conjugated gemcitabine (APT:GEM); and transplant with three kinds of patches: atelocollagen‐aptamer‐gemcitabine (patch I), atelocollagen‐inactive aptamer‐gemcitabine (patch II), and atelocollagen‐gemcitabine (patch III). Tumor volumes and response were evaluated based on histological analysis by H&E staining and Immunohistochemistry (IHC) was performed. Anticancer therapy–related toxicity was evaluated by hematologic findings. The patch I group showed the most significant reduction of tumor growth rate, compared with the no‐treatment group (p < 0.05). However, other treatment groups were not found to show significant reduction in tumor growth rate (0.05 < p < 0.1). There was no microscopic evidence suggesting potential toxicity, such as inflammation, nor necrotic changes in liver, lung, kidney, and spleen tissue. In addition, no leukopenia, anemia, or neutropenia was observed in the patch I group. This implantable aptamer‐drug conjugate system is thought to be a new surgical strategy to augment the oncologic significance of margin‐negative resection in treating pancreatic cancer in near future. [ABSTRACT FROM AUTHOR]

Background: Few studies have compared laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD) despite emerging use of minimally invasive pancreaticoduodenectomy (MIPD). The present study therefore compares perioperative outcomes of LPD and RPD patients, and evaluates safety and feasibility of MIPD. Methods: This retrospective multicenter analysis evaluated MIPD patients through June 2020 performed by three experienced pancreatic surgeons at three different institutions. Perioperative outcomes were compared before and after propensity score‐matching analyses, and learning curves based on operation time were used for additional matching analysis. Results: Of 362 patients, 282 underwent LPD and 80 underwent RPD. Open conversion rate was significantly higher in LPD (P =.001). There were no significant differences in rates of major complications (Clavien‐Dindo ≥III) and clinically relevant postoperative pancreatic fistula (CR‐POPF). After matching, operation time (P =.001) and hospital stay (P =.027) were significantly shorter in RPD, but there were no differences in major complications and CR‐POPF. Propensity score‐matched comparison after learning curve attainment showed shorter operation time (P =.037) and hospital stay (P =.014) in RPD, and no differences in major complications and CR‐POPF. Conclusion: RPD had several advantages compared with LPD, including shorter operative time and hospital stay, and lower open conversion rate. Postoperative complications including CR‐POPF showed comparable results in two groups. Both LPD and RPD seemed to be feasible and safe approaches in experienced hands. [ABSTRACT FROM AUTHOR]

Background: Pancreatoduodenectomy (PD) is the only curative therapy for distal cholangiocarcinoma (dCC). There has been no study to compare outcomes between minimally invasive pancreatoduodenectomy (MIPD) and open pancreatoduodenectomy (OPD) for dCC. The aim of the study is to compare the two operation types for dCC in terms of postoperative and oncologic outcomes. Methods: Data from 426 patients who underwent MIPD (n = 91) or OPD (n = 335) for dCC from January 2012 to December 2019 at two tertiary hospitals were retrospectively reviewed. After 1:2 propensity score matching, postoperative and oncologic outcomes were compared. Results: Minimally invasive pancreatoduodenectomy group showed more favorable results than OPD group in terms of blood loss (MIPD vs OPD, 250 [150‐400] vs 400 [200‐600], mL, P <.001), and length of hospital stay (19.8 ± 11.3 vs 26.6 ± 14.3 days, P <.001). OPD group showed more favorable results than MIPD group in terms of operation time (MIPD vs OPD, 457 ± 70 vs 398 ± 85 min, P <.001) and harvested lymph nodes (14.9 ± 7.8 vs 20.7 ± 11.5, P <.001). There was no statistical difference between the two groups in the R0 resection rate and complications. In long‐term survival analysis, there was no significant difference between the two groups. Conclusion: Minimally invasive pancreatoduodenectomy showed comparable postoperative complications and long‐term oncologic survival with OPD in the treatment of dCC. [ABSTRACT FROM AUTHOR]

Background: Development of a pragmatic pathologic classifier of pancreatic ductal adenocarcinoma (PDAC) that reflects biological behavior is needed. Methods: The tumor epithelial and stromal features of PDAC and molecular subtype‐related markers were evaluated in three independent cohorts. Results: In the non‐neoadjuvant therapy cohort (n = 108), regarding tumor‐epithelial feature, non‐gland‐forming type showed worse prognosis compared to gland‐forming type (P <.001). For tumor‐stromal feature, in gland‐forming type, the prognosis was good in order of inactivated stroma‐rich, stroma‐poor, and activated stroma‐rich (P =.027). Whereas, non‐gland‐forming type revealed no difference of prognosis according to tumor stroma. Of molecular subtype‐related markers, keratin 81 expression was correlated with non‐gland‐forming type and poor prognosis (P =.005 and P =.021, respectively). Other markers (HNF1A, c‐MET, and p53) showed no significant differences in prognosis. In the neoadjuvant therapy cohort (n = 68), non‐gland‐forming type was correlated with high residual tumor volume (≥20%) (P <.001) and gland‐forming/stroma‐poor type was not present. In the next‐generation sequencing cohort (n = 55), non‐gland‐forming type was correlated with a higher number of the KRAS, TP53, CDKN2A, and SMAD4 mutations (P =.038). Conclusion: Combined tumor epithelial and stromal histopathology with keratin 81 expression is suggested to be useful for predicting prognosis of PDAC. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive distal pancreatectomy (MIDP) was initially performed for benign tumors, but recently its indications have steadily broadened to encompass other conditions including pancreatic malignancies. Thorough anatomical knowledge is mandatory for precise surgery in the era of minimally invasive surgery. However, expert consensus regarding anatomical landmarks to facilitate the safe performance of MIDP is still lacking. Methods: A systematic literature search was performed using keywords to identify articles regarding the vascular anatomy and surgical approaches/techniques for MIDP. Results: All of the systematic reviews revealed that MIDP was not associated with an increase in postoperative complications. Moreover, most showed that MIDP resulted in less blood loss than open surgery. Regarding surgical approaches for MIDP, a standardized stepwise procedure improved surgical outcomes, including blood loss, operative time, and major complications. There are two approaches to the splenic vessels, superior and inferior; however, no study has ever directly compared them with respect to clinical outcomes. The morphology of the splenic artery affects the difficulty of approaching the artery's root. To select an appropriate dissecting layer when performing posterior resection, thorough knowledge of the anatomy of the fascia, left renal vein/artery, and left adrenal gland is needed. Conclusions: In MIDP, a standardized approach and precise knowledge of anatomy facilitates safe surgery and has the advantage of a shorter learning curve. Anatomical features and landmarks are particularly important in cases of radical MIDP and splenic vessel preserving MIDP. [ABSTRACT FROM AUTHOR]

Background: The anatomical structure around the pancreatic head is very complex and it is important to understand its precise anatomy and corresponding anatomical approach to safely perform minimally invasive pancreatoduodenectomy (MIPD). This consensus statement aimed to develop recommendations for elucidating the anatomy and surgical approaches to MIPD. Methods: Studies identified via a comprehensive literature search were classified using the Scottish Intercollegiate Guidelines Network method. Delphi voting was conducted after experts had drafted recommendations, with a goal of obtaining >75% consensus. Experts discussed the revised recommendations with the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Results: Three clinical questions were addressed, providing six recommendations. All recommendations reached at least a consensus of 75%. Preoperatively evaluating the presence of anatomical variations and superior mesenteric artery (SMA) and superior mesenteric vein (SMV) branching patterns was recommended. Moreover, it was recommended to fully understand the anatomical approach to SMA and intraoperatively confirm the SMA course based on each anatomical landmark before initiating dissection. Conclusions: MIPD experts suggest that surgical trainees perform resection based on precise anatomical landmarks for safe and reliable MIPD. [ABSTRACT FROM AUTHOR]

Background: Surgical views with high resolution and magnification have enabled us to recognize the precise anatomical structures that can be used as landmarks during minimally invasive distal pancreatectomy (MIDP). This study aimed to validate the usefulness of anatomy‐based approaches for MIDP before and during the Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (February 24, 2021). Methods: Twenty‐five international MIDP experts developed clinical questions regarding surgical anatomy and approaches for MIDP. Studies identified via a comprehensive literature search were classified using Scottish Intercollegiate Guidelines Network methodology. Online Delphi voting was conducted after experts had drafted the recommendations, with the goal of obtaining >75% consensus. Experts discussed the revised recommendations in front of the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Results: Four clinical questions were addressed, resulting in 10 recommendations. All recommendations reached at least a 75% consensus among experts. Conclusions: The expert consensus on precision anatomy for MIDP has been presented as a set of recommendations based on available evidence and expert opinions. These recommendations should guide experts and trainees in performing safe MIDP and foster its appropriate dissemination worldwide. [ABSTRACT FROM AUTHOR]

Background: To evaluate a risk‐adjusted comparison of clinically relevant postoperative pancreatic fistula POPF (CR‐POPF) following laparoscopic pancreatoduodenectomy (LPD) vs open pancreatoduodenectomy (OPD) using the fistula risk score (FRS). Methods: We retrospectively analyzed 579 patients who underwent LPD (n = 274) or OPD (n = 305) between 2012 and 2019 at two tertiary hospitals. Using the FRS, the risk was stratified into four categories; negligible, low, intermediate and high risk. Results: The median FRS was significantly higher in the LPD than in the OPD group (5.4 ± 1.2 vs 3.9 ± 1.8, P <.001). The overall incidence of CR‐POPF in the LPD vs OPD groups were 16.4% vs 17.7% (P =.187). When POPF risks were stratified by FRS, CR‐POPF following LPD vs OPD in patients with low risk (0% vs 6.3%, P =.294), intermediate risk (16.1% vs 22.9%, P =.053) and high risk (33.3% vs 27.3%, P =.577) were not significantly different. Conclusion: Despite a higher risk score in the LPD group, the CR‐POPF was similar following both procedures in the unadjusted and FRS‐risk‐adjusted comparisons. The CR‐POPF was more significantly affected by patient risk factors such as the soft pancreas and small pancreatic duct. [ABSTRACT FROM AUTHOR]

Background: There has been increasing attention on the subjective recovery of patients undergoing cancer surgery. Total intravenous anesthesia (TIVA) and inhaled anesthesia with volatile anesthetics (INHA) are safe and common anesthetic techniques. Currently, TIVA and INHA have only been compared for less invasive and less complex surgeries. This prospective randomized trial aimed to compare the quality of recovery between TIVA and INHA in patients undergoing pancreatoduodenectomy (PD) or distal pancreatectomy (DP) using the Quality of Recovery (QOR)-40 questionnaire. Methods: We enrolled 132 patients who were randomly assigned to either the desflurane (DES) (INHA, balanced anesthesia with DES and remifentanil infusion) or TIVA (effect-site target-controlled infusion of propofol and remifentanil) groups and completed the QOR-40 questionnaire postoperatively. Results: The mean global QOR-40 score on postoperative day 3 was significantly higher in the TIVA group than in the DES group. In the PD group, the total QOR-40 score was significantly higher in the TIVA group than in the DES group. Moreover, the TIVA group had significantly higher scores in the physical comfort and psychological support QOR-40 dimensions than the DES group. Conclusion: TIVA provides better quality of recovery scores on POD 3 for patients undergoing curative pancreatectomy. Clinical trial registration number: NCT03447691 [ABSTRACT FROM AUTHOR]

Background: Adjuvant therapy is beneficial in prolonging survival in patients with pancreatic ductal adenocarcinoma (PDAC). However, no clear guidelines are available on the oncologic effect of adjuvant therapy in resected invasive intraductal papillary mucinous neoplasms (inv‐IPMN). Methods: In total, 551 patients with PDAC and 67 patients with inv‐IPMN of the pancreas were reviewed. For external validation, 46 patients with inv‐IPMN from six other Korean institutions were enrolled. Propensity score‐matched analysis and stage‐matched survival analysis were conducted. Results: The mean follow‐up durations in the inv‐IPMN and PDAC groups were 43.36 months (SD, 42.34 months) and 43.35 months (SD, 35.62 months), respectively. The 5‐year overall survival (OS) was significantly better in the resected inv‐IPMN group than in the PDAC group in the overall stage‐matched analysis (P <.001). In the inv‐IPMN cohort, OS was better in the surgery alone group (P =.042). In subgroup analysis, no significant survival difference was found between the adjuvant therapy and surgery alone groups according to the stage (stage I; P =.285, stage II or III; P =.077). Multicenter external validation did not show a better OS in the adjuvant therapy group (P =.531). On multivariable analysis, only perineural invasion (PNI) was identified as an adverse prognostic factor in resected inv‐IPMN (HR 4.844; 95% CI 1.696‐13.838, P =.003). Conclusions: inv‐IPMN has a more indolent course than PDAC. Current strategy of adjuvant therapy may not improve the OS in patients with resected inv‐IPMN. Further investigations on the potential role of adjuvant therapy in inv‐IPMN are mandatory. [ABSTRACT FROM AUTHOR]

Background: Hypocapnia has been traditionally advocated during general anesthesia, even though it may induce deleterious physiological effects that result in unfavorable outcomes in patients. This study investigated the association between intraoperative end-tidal carbon dioxide (EtCO2) and length of hospital stay (LOS) in patients who underwent pylorus-preserving pancreaticoduodenectomy (PPPD). Methods: The medical records of 759 patients from 2006 to 2015 were reviewed. The patients were divided into two groups based on the mean EtCO2 value during general anesthesia: the hypocapnia group (< 35 mmHg) and the normocapnia group (≥ 35 mmHg). The primary outcome was LOS between the groups. Secondary outcomes included the length of intensive care unit (ICU) stay, postoperative 30-day, 1-year, and 2-year mortality, and perioperative factors associated with LOS. Results: A total of 727 patients were finally analyzed. The median LOS of the hypocapnia group was significantly longer than that of the normocapnia group (22 days vs. 18 days, respectively; p < 0.001). Postoperative mortality did not differ between the groups. Cox regression analysis revealed that hypocapnia was an independent risk factor for longer LOS (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.37–1.89; p < 0.001). Age and postoperative pancreatic fistula were also risk factors for a longer LOS. Conclusions: It was concluded that low levels of intraoperative EtCO2 during general anesthesia were associated with an increased LOS for patients undergoing PPPD. [ABSTRACT FROM AUTHOR]

Background: Complications are important indicators of immediate postoperative outcomes. The Clavien–Dindo classification (CDC) is a widely used index for the classification of surgical complications. More recently, the comprehensive complication index (CCI) has also been introduced for classifying postoperative complications. The aim of this study was to compare the relationship of CCI and CDC with clinical or economic parameters. Methods: The study prospectively enrolled patients from April 2015 to October 2016. Two hundred and twenty-two patients underwent pancreatectomy during the enrolled period. Complications were ranked according to CDC and CCI indices. After analyzing the correlation between CCI and CDC, the correlations of length of stay (LOS) and cost with CCI and CDC were compared. Finally, differences between the correlation coefficients of CDC and CCI parameters were calculated. Results: Complications occurred in 211 patients (95.0%). The correlation between CDC and CCI was r = 0.938. (p < 0.001) Compared to the CDC, CCI showed significantly stronger correlations with LOS and cost of complications (LOS: CCI vs. CDC, r = 0.725 vs. r = 0.630, p < 0.001; cost: CCI vs. CDC, r = 0.774 vs. r = 0.723, p < 0.001). Conclusion: CCI is a more accurate classification index, compared to CDC, for evaluating the risk of postoperative complications. [ABSTRACT FROM AUTHOR]

Background and Aim: The aim of this study is to identify the predictive factors for futile surgery in patients with radiologically resectable or borderline resectable pancreatic cancer and to develop a prediction model. Methods: This retrospective study included patients who underwent pancreatic surgery for pancreatic cancer between 2006 and 2017. To identify independent risk factors for futile surgery, logistic regression and random forest analyses were performed in the training cohort, based on which a nomogram was established. The predictive accuracy and discriminative ability of the nomogram were validated in the validation cohort. Results: Of 389 patients who underwent pancreatic surgery, the laparotomy was futile in 40 patients (10.3%). In the training cohort, the univariate and multivariate logistic regression analyses revealed that serum carbohydrate antigen 19‐9 level of ≥ 150 U/mL (P = 0.003), the presence of suspicious lymph node (P = 0.013), and more extensive peripancreatic tumor infiltration (P < 0.001) were independent predictive factors for futile surgery. The bootstrap‐corrected concordance index of the nomogram was high in the training cohort, 0.826 with a 95% confidence interval of 0.745–0.907. This model also showed a good discriminative performance in the validation cohort, with a concordance index of 0.831. Conclusions: We established and validated a novel nomogram that predicts the risk of futile surgery due to occult distant metastasis in patients with radiologically resectable or borderline resectable pancreatic cancer. [ABSTRACT FROM AUTHOR]

Laparoscopic pancreaticoduodenectomy (LPD) is technically feasible, but its safety is still controversial. Pancreas texture and the small size of the main pancreatic duct indicate laparoscopic pancreaticoduodenectomy (LPD) as a challenging procedure. Thus, LPD could be a risk factor for postoperative pancreatic fistula (POPF), longer hospital stay, and delayed adjuvant chemotherapy that affects long‐term oncologic outcome. So, it is important to promote education on LPD especially techniques for pancreaticojejunostomy. A porcine model for duct‐to‐mucosa pancreaticojejunostomy (PJ) (Yonsei‐PJDTM) was developed, and details of the model will be described in this report. [ABSTRACT FROM AUTHOR]

Background: Both the technical and oncological safety of laparoscopic pancreaticoduodenectomy (LPD) remain controversial in treating pancreatic head cancer. We evaluated the oncologic benefit of LPD and compared the inflammatory score between LPD and open pancreaticoduodenectomy (OPD). Methods: From January 2014 to March 2019, 61 patients with standard PD not combined with other organ resection were finally enrolled in this study. Among these patients, 27 underwent LPD and 34 underwent OPD (registered on 16 July 2019, and registration number is 2019‐1411‐001). Results: The estimated blood loss (EBL) for the LPD group was less than that of the OPD group (P = 0.003). The operation time was similar, as was the incidence of complications such as postoperative fistula, delayed gastric emptying. Overall survival was not different between LPD and OPD (44.62 vs. 45.29 months, P = 0.223). However, a significant improvement in disease‐free survival (DFS) was seen in the LPD group (34.19 vs. 23.27 months, P = 0.027). No statistically significant differences were found in terms of the postoperative change in inflammatory scores and differentiated white blood cell counts. Conclusions: LPD is not only safe and feasible in pancreatic head cancer patients but is associated with a reduced amount of EBL, favorable DFS. [ABSTRACT FROM AUTHOR]

Background: To compare the effectiveness of a custom-made skills simulator (CMSS) with the commercially available da Vinci® skills simulator (DVSS) that help improving surgical skills for effective and safe robotic surgical interventions. Methods: A randomized control study was conducted to determine the performance of participants after undergoing robotic surgical training. Total 64 students who had no previous experience with robotic surgery enrolled this study. After 5 min—introduction of robotic surgical system, the participants got random-assignment into two groups to perform either CMSS-or DVSS-exercises. After 15 min-practicing the corresponding simulator, task-execution performance and individual questionnaires were compared between participants trained with the CMSS and those trained with the DVSS. Results: Regardless of simulator the participants used, the system understanding and manipulation ability of the participants was found to be higher than after completing the simulation-based robotic surgical training (p < 0.05). However, there were no significant differences in terms of the required time to complete the tasks, and improvement of understanding the concept of robotic surgery, or surgical skill capacity between two groups (p > 0.05). Conclusions: The training effectiveness of CMSS was not significantly different to DVSS. It can be synergetic tool to DVSS for novice trainees of robotic surgery to get accustomed to the robotic surgical system and to improve their basic robotic surgical skills. [ABSTRACT FROM AUTHOR]

Because of today's advancements in surgical techniques and perioperative management skills, surgeons are beginning to explore the usefulness of the laparoscopic approach in managing periampullary tumors. However, as a result of its innate complexity and associated high surgery‐related complications, its applicability to the general surgical community remains controversial. To date, only retrospective data from high‐volume centers support the safety and feasibility of laparoscopic pancreaticoduodenectomy (Lap PD) for the treatment of benign conditions and malignant periampullary tumors. In addition, various surgical techniques in terms of port placement, dissection, and reconstruction have evolved in different centers depending on the preferred method commonly used by the surgeon through accumulated experience. In our center, we used a stepwise approach and standardized our surgical technique to overcome this technically demanding procedure. A collaborative implementation of video review and analysis, practice training and simulation, operating room didactics, and strict adherence to our stepwise approach in Lap PD, might potentially improve the surgical skills of young hepatobiliary surgeons and possibly overcome the volume‐based learning curve of Lap PD. [ABSTRACT FROM AUTHOR]

Background: Immunologic factors such as neutrophil‐lymphocyte ratio and platelet‐lymphocyte ratio play an important role in predicting the oncologic outcome of patients in pancreatic ductal adenocarcinoma (PDAC). It is hypothesized that host immunity represented by total lymphocyte count at diagnostic stage would influence oncologic outcome in left‐sided PDAC. Methods: Between January 1992 and August 2017, total of 112 patients who underwent distal pancreatectomy for left‐sided PDAC were included and analysed. Results: At the time of the diagnosis, total lymphocyte count at diagnosis of left‐sided PDAC was 1.8 ± 0.7 103/μL (mean value ± standard deviation). Among different cut‐off values, 1.7 showed most powerful significant differences in long‐term oncologic outcomes. The patients with preoperative lymphocyte count (≤1.7) was associated with early recurrence (median 8.4 months versus 18.1 months, P = 0.011) and shorter survival (median 18.6 months versus 35.9 months, P = 0.028). Patients with preoperative total lymphocyte count over 1.7 showed higher white blood cell count (P < 0.001), platelet count (P = 0.039), neutrophil count (P = 0.004) and monocyte count (P = 0.001). However, more interestingly, neutrophil‐lymphocyte ratio (P < 0.001) and platelet‐lymphocyte ratio (P < 0.001) were found to be significantly higher in those with total lymphocyte count less than 1.7. Lymphocyte to monocyte ratio was inversely related to preoperative total lymphocyte count (P < 0.001). Only age was identified to be significantly different (P = 0.007). However, other clinicopathological parameters generally known to be related to tumour aggressiveness, were not different between two groups. Conclusion: In conclusion, preoperative total lymphocyte at diagnostic stage is simple, and good prognostic factor in left‐sided pancreatic cancer. [ABSTRACT FROM AUTHOR]

Background: Although organ-preserving operations are regarded as effective strategies for duodenal gastrointestinal stromal tumors (GISTs), laparoscopic partial sleeve duodenectomy (lap PSD) has not been fully evaluated. The aims of this study were to evaluate the effectiveness and technical feasibility of lap PSD.Study design: Between January 2011 and March 2016, we reviewed 13 patients who underwent laparoscopic approach among 22 patients who underwent PSD. PSD for the infra-ampullary lesions was defined as infra-ampullary duodenal resection including the first portion of the jejunum. After resection, all patients underwent reconstruction via side-to-side duodenojejunostomy.Results: The total mean operation time was 273 min (range 160-346 min), and estimated mean blood loss was 80 ml (range scanty-200 ml). One patient was converted to open laparotomy because of mesocolonic tumor involvement. The median postoperative hospital stay was 10.5 days (range 4-36 days). There were no postoperative mortalities. Postoperative complications included 2 instances of delayed gastric emptying (DGE), 1 duodenojejunostomy stricture, and 2 intestinal obstructions. No patient was treated with adjuvant therapy. One patient experienced hepatic metastasis 28 months after surgery during a mean follow-up period of 48.6 months.Conclusion: Lap PSD might be an oncologically effective strategy for duodenal GIST, and the laparoscopic approach is a technically feasible and appealing surgical modality in terms of safety and perioperative results. However, DGE and anastomosis strictures are concerns for postoperative complications, which need to be further investigated. [ABSTRACT FROM AUTHOR]

Background: Simultaneous division of the splenic artery, splenic vein and pancreatic parenchyma during laparoscopic distal pancreatosplenectomy (LDPS) is known as the lasso technique, which is considered to be simple to perform. However, the original lasso technique carries a risk of post‐operative bleeding from the splenic artery. We modified the original lasso technique to improve its technical safety and compared the perioperative outcomes of LDPS performed with the modified lasso technique (ml‐LDPS) with those of conventional LDPS (c‐LDPS). Methods: From August 2006 to July 2016, 30 patients underwent c‐LDPS and 31 patients underwent ml‐LDPS for distal pancreatectomy involving <50% of the pancreas. The perioperative outcomes of the two groups were compared. Results: The ml‐LDPS technique resulted in a shorter operation time (201 min versus 162 min, P < 0.01), less intraoperative blood loss (20 mL versus 200 mL, P < 0.01), a shorter post‐operative hospital stay (8.0 days versus 12.5 days, P < 0.01), and a lower incidence of clinically relevant post‐operative pancreatic fistulas (6.5% versus 26.7%, P = 0.04) compared with c‐LDPS. The surgical approach (c‐LDPS or ml‐LDPS) was identified as an independent predictor of the development of clinically relevant post‐operative pancreatic fistulas via multivariate analysis. Conclusion: The ml‐LDPS method had beneficial effects on the operation time, intraoperative bleeding, the post‐operative morbidity rate and the length of the post‐operative hospital stay. The ml‐LDPS procedure is a simple, safe and effective way of performing planned LDPS. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to investigate the prognostic impact of transfusion following distal pancreatectomy (DP) for left‐sided pancreatic ductal adenocarcinoma (PDAC). Methods: Retrospective analysis was performed to identify prognostic factors in patients who underwent DP from July 1992 to October 2012. Results: Forty‐eight patients were male, and 35 were female with a mean age of 62 ± 9 years. Twenty‐three (27.7%) of the patients received intraoperative blood transfusion. In univariate analysis, combined organ resection (P = 0.046), intraoperative transfusion (P < 0.001), pathologic tumor size (≥3 cm, P = 0.051), clinical tumor size (≥3 cm, P = 0.008), lymph node metastasis (P = 0.021), lymph node ratio (LNR ≥ 0.017, P < 0.001), and tumor differentiation (P = 0.013) were analyzed to predict tumor recurrence. Multivariate analysis showed that lymph node metastasis (Exp(β) = 2.136, P = 0.016), LNR (Exp(β) = 2.003, P = 0.049), and intraoperative transfusion (Exp(β) = 2.793, P = 0.001) were independent prognostic factor predicting tumor recurrence. The amount of estimated blood loss was closely associated with intraoperative transfusion (P < 0.001). Conclusion: Intraoperative transfusion should be avoided by gentle operative handling to minimize intraoperative bleeding, and the appropriate transfusion policy should be followed to increase the survival outcome. Highlight Hwang and colleagues demonstrated that lymph node metastasis, lymph node ratio, and intraoperative transfusion were independent prognostic factors in patients with left‐sided pancreatic cancer who underwent curative distal pancreatectomy, suggesting that meticulous surgical technique as well as the adoption of an appropriate transfusion policy are indispensable to improve survival outcomes. [ABSTRACT FROM AUTHOR]

Background: The present study investigates the clinical impact of Braun anastomosis on delayed gastric emptying (DGE) after pylorus‐preserving pancreaticoduodenectomy (PPPD). Methods: From February 2013 to June 2014, 60 patients were recruited for this randomized controlled trial. The incidence of DGE and its risk factors were analyzed according to whether or not Braun anastomosis was used after PPPD. Results: Thirty patients were respectively enrolled in No‐Braun group and Braun group. A comparative analysis between the two groups showed no differences in sex, diagnosis, operation time, hospital stay, or postoperative complications, including pancreatic fistula. Overall DGE developed in eight patients (26.7%) in the Braun group and in 14 patients (46.7%) in the No‐Braun group (P = 0.108). However, clinically relevant DGE (grades B and C) was marginally more frequent in the No‐Braun group (23.3% vs. 3.3%, P = 0.052). In a multivariable analysis, No‐Braun anastomosis was an independent risk factor for developing clinically relevant DGE (odds ratio = 16.489; 95% confidence interval: 1.287–211.195; P = 0.031). Conclusion: The overall DGE occurrence was not different between the two groups. However, No‐Braun anastomosis was an independent risk factor for developing clinically relevant DGE. Highlight In this randomized controlled trial to evaluate the effectiveness of Braun anastomosis in reducing delayed gastric emptying (DGE) after pylorus‐preserving pancreaticoduodenectomy, Hwang and colleagues found no difference in overall DGE occurrence between the groups. However, the absence of Braun anastomosis was an independent risk factor developing clinically relevant DGE. [ABSTRACT FROM AUTHOR]

Background: We performed a prospective, multicenter, randomized controlled study to investigate the clinical outcomes, including postoperative pancreatic fistulas (POPF), after using the TachoSil® patch in distal pancreatectomy (NCT01550406). Methods: Between June 2012 and September 2014, 101 patients at five centers were randomized into Control (n = 53) and TachoSil (n = 48) groups. In all patients, the pancreas was resected using a stapler with Endo‐GIA™ staples. The TachoSil patch was wrapped around the pancreatic stump only in the TachoSil group, not in Control group. Results: The patient characteristics, including age and diagnosis, were comparable in both groups. The mean operation time (159.4 vs. 172.3 min, P = 0.081) and postoperative hospital stay (10.0 vs. 9.7 days, P = 0.279) were similar in the Control and TachoSil groups, respectively. The overall incidence of POPF was 62.4% (n = 63). The distribution of grades A, B, and C POPF was similar in the Control (n = 14/14/1) and TachoSil (n = 23/11/0) groups, as were the overall incidence (54.7% vs. 70.8%, P = 0.095) and the incidence of grade B and C POPF (28.3% vs. 22.9%, P = 0.536). Conclusion: This study showed that the TachoSil® patch did not reduce the incidence of POPF after distal pancreatectomy. Highlight The authors performed a prospective, multicenter, ramdomized controlled study to investigate the efficacy of TachoSil® patches in preventing pancreatic fistula, the most frequent and serious complication after distal pancreatectomy, for which effective prevention and management methods remain lacking. The patch did not reduce the incidence of postoperative pancreatic fistula. [ABSTRACT FROM AUTHOR]

With the advance of laparoscopic experiences and techniques, it is carefully regarded that laparoscopic pancreaticoduodenectomy (lap‐PD) is feasible and safe in managing perimapullary pancreatic pathology. Especially, laparoscopic management of remnant pancreas can be a critical step toward completeness of minimally invasive PD. According to available published reports, there is a wide range of technical differences in choosing surgical options in managing remnant pancreas after lap‐PD. For the evidence‐based surgical approach, it would be ideal to test potential techniques by randomized controlled trials, but, currently, it is thought to be very difficult to expect those clinical trials to be successful because there are still a lack of expert surgeons with sound surgical techniques and experience. In addition, lap‐PD is so complicated and technically demanding that many surgeons are still questioning whether this surgical approach could be standardized and popular like laparoscopic cholecystectomy. In general, surgical options are usually chosen based on following question: (1) Is it simple? (2) Is it easy and feasible? (3) Is it secure and safe? (4) Is there any supporting scientific evidence? It would be interesting to estimate which surgical technique would be appropriate in managing remnant pancreas under these considerations. It is hoped that a well standardized multicenter‐based randomized control study would be successful to test this fundamental issues based on sound surgical techniques and scientific background. [ABSTRACT FROM AUTHOR]

There is controversy regarding the recommended surgical approach for pancreatic tumors near the neck or proximal body of the pancreas. Unlike pancreatic cancer patients, those with benign and borderline (low‐grade) malignant tumors of the pancreas are expected to have long‐term survival after successful pancreatic resection. Therefore, surgeons need to consider not only oncologic safety, but also quality of life in their choice of surgical treatment. Laparoscopic central pancreatectomy (CP) is an ideal approach for pancreatic tumors near the neck or proximal body of the pancreas because it preserves endocrine and exocrine pancreatic function and conserves spleen function. Consequentially, CP can improve quality of life. However, there are no standardized studies supporting the use of laparoscopic CP. In this manuscript, we review the current status of minimally invasive CP in the advanced laparoscopic era and assess the quality of the evidence supporting the use of CP. We also propose future directions for scientific efforts to assess the utility of this surgical approach for benign and borderline malignant tumors near the neck of the pancreas. [ABSTRACT FROM AUTHOR]

Background: When distal pancreatectomy is carried out for left-sided pancreatic cancer, splenectomy is usually performed not only for margin-negative resection but also for effective clearance of the splenic hilar lymph nodes (LNs). However, the incidence of splenic hilar LN metastasis in these patients has not been definitively determined. Methods: From April 2010 to June 2011, in a pilot study, we analyzed the medical records of twelve patients who had undergone radical antegrade modular pancreatosplenectomy. Potential remnant soft tissue around the splenic hilum, which would be left following an extended Warshaw's procedure, was dissected and sent to a pathologist. Three Japanese medical centers conducted a retrospective survey of splenic hilar lymph node metastasis in left-sided pancreatic cancer to support our study. Results: In the pilot study, all twelve patients had adenocarcinoma with a median tumor size of 2 cm. Six patients had LN metastasis and a median number of 4 splenic hilar LNs were evaluated; however, no splenic hilar LN metastasis was noted. In the Japanese multicenter survey ( n = 85), only four patients had splenic LN metastasis. Small (<3 cm) and proximal (neck/body) left-sided pancreatic cancer might not be associated with splenic hilar LN metastasis ( P < 0.05). Conclusions: In well-selected left-sided pancreatic cancer, the incidence of splenic hilar LN metastasis is low enough that splenectomy-omitting radical distal pancreatectomy would be feasible. The rationale for routine splenectomy should be re-evaluated, and the oncologic effects of the preserved spleen need to be investigated further. [ABSTRACT FROM AUTHOR]

Introduction: We report our experience with laparoscopic major liver resection in Korea based on a multicenter retrospective study. Materials and methods: Data from 1,009 laparoscopic liver resections conducted from 2001 to 2011 were retrospectively collected. Twelve tertiary medical centers with specialized hepatic surgeons participated in this study. Results: Among 1,009 laparoscopic liver resections, major liver resections were performed in 265 patients as treatment for hepatocellular carcinoma, metastatic tumor, intrahepatic duct stone, and other conditions. The most frequently performed procedure was left hemihepatectomy (165 patients), followed by right hemihepatectomy (53 patients). Pure laparoscopic procedure was performed in 190 patients including 19 robotic liver resections. Hand-assisted laparoscopic liver resection was performed in three patients and laparoscopy-assisted liver resection in 55 patients. Open conversion was performed in 17 patients (6.4 %). Mean operative time and estimated blood loss in laparoscopic major liver resection was 399.3 ± 169.8 min and 836.0 ± 1223.7 ml, respectively. Intraoperative transfusion was required in 65 patients (24.5 %). Mean postoperative length of stay was 12.3 ± 7.9 days. Postoperative complications were detected in 53 patients (20.0 %), and in-hospital mortality occurred in two patients (0.75 %). Mean number and mean maximal size of resected tumors was 1.22 ± 1.54 and 40.0 ± 27.8 mm, respectively. R0 resection was achieved in 120 patients with hepatic tumor, but R1 resection was performed in eight patients. Mean distance of safe resection margin was 14.6 ± 15.8 mm. Conclusions: Laparoscopic major liver resection has become a reliable option for treatment of liver disease in Korea. [ABSTRACT FROM AUTHOR]

Background: Single-incision laparoscopic cholecystectomy (LC) is still technically demanding and usually requires specially designed instruments. This article describes our own technique, a single-fulcrum LC using only standard ports and instruments. Methods: Between March 2009 and December 2010, 130 consecutive patients, all scheduled to undergo elective LC, underwent this single-fulcrum LC for benign gallbladder disease. Perioperative surgical outcomes were retrospectively evaluated. Results: One hundred and ten patients (84.6%) underwent successful single-fulcrum LC, and 20 patients (15.4%) were converted to conventional surgery ( n= 18) or required additional trocars ( n= 2) during the procedure because of umbilical hernia ( n= 3), severe inflammation or adhesion ( n= 9), impacted cystic duct stone ( n= 3), anatomical anomaly ( n= 3) and iatrogenic injury ( n= 2). Two intraoperative complications (iatrogenic injury) were securely managed using additional trocars and there was no post-operative morbidity or mortality. This single-fulcrum LC could be performed with comparable cost to conventional LC, and the sequential operative time showed reasonable learning curve. Conclusion: Single-fulcrum LC is feasible, safe and quite reproducible. The surgical wound can be dramatically reduced at a similar cost to conventional LC. It may be an alternative procedure for most uncomplicated benign gallbladder disease. [ABSTRACT FROM AUTHOR]