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BACKGROUND: Robot-assisted distal pancreatectomy (RDP) is increasingly used as an alternative to laparoscopic distal pancreatectomy (LDP) in patients with resectable pancreatic cancer but comparative multicenter studies confirming the safety and efficacy of RDP are lacking. METHODS: An international, multicenter, retrospective, cohort study, including consecutive patients undergoing RDP and LDP for resectable pancreatic cancer in 33 experienced centers from 11 countries (2010-2019). The primary outcome was R0-resection. Secondary outcomes included lymph node yield, major complications, conversion rate, and overall survival. RESULTS: In total, 542 patients after minimally invasive distal pancreatectomy were included: 103 RDP (19%) and 439 LDP (81%). The R0-resection rate was comparable (75.7% RDP vs. 69.3% LDP, p = 0.404). RDP was associated with longer operative time (290 vs. 240 min, p < 0.001), more vascular resections (7.6% vs. 2.7%, p = 0.030), lower conversion rate (4.9% vs. 17.3%, p = 0.001), more major complications (26.2% vs. 16.3%, p = 0.019), improved lymph node yield (18 vs. 16, p = 0.021), and longer hospital stay (10 vs. 8 days, p = 0.001). The 90-day mortality (1.9% vs. 0.7%, p = 0.268) and overall survival (median 28 vs. 31 months, p = 0.599) did not differ significantly between RDP and LDP, respectively. CONCLUSIONS: In selected patients with resectable pancreatic cancer, RDP and LDP provide a comparable R0-resection rate and overall survival in experienced centers. Although the lymph node yield and conversion rate appeared favorable after RDP, LDP was associated with shorter operating time, less major complications, and shorter hospital stay. The specific benefits associated with each approach should be confirmed by multicenter, randomized trials.

Background Benchmarking is the process to used assess the best achievable results and compare outcomes with that standard. This study aimed to assess best achievable outcomes in minimally invasive distal pancreatectomy with splenectomy (MIDPS). Methods This retrospective study included consecutive patients undergoing MIDPS for any indication, between 2003 and 2019, in 31 European centres. Benchmarks of the main clinical outcomes were calculated according to the Achievable Benchmark of Care (ABC™) method. After identifying independent risk factors for severe morbidity and conversion, risk-adjusted ABCs were calculated for each subgroup of patients at risk. Results A total of 1595 patients were included. The ABC was 2.5 per cent for conversion and 8.4 per cent for severe morbidity. ABC values were 160 min for duration of operation time, 8.3 per cent for POPF, 1.8 per cent for reoperation, and 0 per cent for mortality. Multivariable analysis showed that conversion was associated with male sex (OR 1.48), BMI exceeding 30 kg/m2 (OR 2.42), multivisceral resection (OR 3.04), and laparoscopy (OR 2.24). Increased risk of severe morbidity was associated with ASA fitness grade above II (OR 1.60), multivisceral resection (OR 1.88), and robotic approach (OR 1.87). Conclusion The benchmark values obtained using the ABC method represent optimal outcomes from best achievable care, including low complication rates and zero mortality. These benchmarks should be used to set standards to improve patient outcomes.

(1) Background: Perineural invasion (PNI) is a common characteristic of pancreatic ductal adenocarcinoma (PDAC) and is present in most resection margins. We hypothesized that curative pancreatic tumor resection with long-term survival could only be achieved in PNI-negative patients. (2) Material and Methods: A retrospective investigation of PDAC patients who underwent curative-intended surgery during the period 2008 to 2019 was performed at our institution. (3) Results: We identified 571 of 660 (86.5%) resected patients with well-annotated reports and complete datasets. Of those, 531 patients (93%) exhibited tumors with perineural invasion (Pn1), while 40 (7%) were negative for PNI (Pn0). The majority of patients in the Pn1 group presented advanced tumor stage and positive lymph node infiltration. Patients in the Pn0 group showed an improved disease-free and long-term survival compared to the Pn1 group (p < 0.001). Subgroup analysis of all R0-resected patients indicated improved long-term survival and disease-free survival of R0 Pn0 patients when compared to R0 Pn1 patients (p < 0.001). (4) Conclusion: Our study confirmed that Pn0 improves the long-term survival of PDAC-resected cancer patients. Furthermore, PNI significantly challenges the long-term survival of formally curative (R0) resected patients. We provide new insights into the dynamics of PNI in pancreatic cancer patients which are needed to define subgroups of patients for risk stratification and multimodal treatment strategies.

Simple Summary: Long-term immunosuppressive therapy following liver transplantation is associated with an increased risk for the development of de novo lung carcinoma. However, data on the management of the immunosuppression following the diagnosis of lung cancer are missing to the present day. In this retrospective analysis, we investigate factors associated with improved survival of liver transplant recipients with diagnosis of de novo lung carcinoma with a particular emphasis on the impact of immunosuppression. Our findings suggest that strict reduction of immunosuppression has a beneficial effect on survival in this particular situation and, thus, should be an early intervention following diagnosis. Liver transplant recipients with the diagnosis of de novo lung cancer should be offered surgical treatment if technically feasible as a potential curative therapeutic option to improve limited prognosis. Further investigations concerning dosage findings and reduction of immunosuppression in organ recipients should be the targets of subsequent studies. Abstract: (1) Background: Liver transplantation (LT) is an established treatment for selected patients with end-stage liver disease resulting in a subsequent need for long-term immunosuppressive therapy. With cumulative exposure to immunosuppression (IS), the risk for the development of de novo lung carcinoma increases. Due to limited therapy options and prognosis after diagnosis of lung cancer, the question of the mode and extent of IS in this particular situation is raised. (2) Methods: All patients diagnosed with de novo lung cancer in the follow-up after LT were identified from the institution's register of liver allograft recipients (Charite-Universitatsmedizin Berlin, Germany) transplanted between 1988 and 2021. Survival analysis was performed based on the IS therapy following diagnosis of lung cancer and the oncological treatment approach. (3) Results: Among 3207 adult LTs performed in 2644 patients at our institution, 62 patients (2.3%) developed de novo lung carcinoma following LT. Lung cancer was diagnosed at a median interval of 9.7 years after LT (range 0.7-27.0 years). Median survival after diagnosis of lung carcinoma was 13.2 months (range 0-196 months). Surgical approach with curative intent significantly prolonged survival rates compared to palliative treatment (median 67.4 months vs. 6.4 months). Reduction of IS facilitated a significant improvement in survival (median 38.6 months vs. 6.7 months). In six patients (9.7%) complete IS weaning was achieved with unimpaired liver allograft function. (4) Conclusion: Reduction of IS therapy after the diagnosis of de novo lung cancer in LT patients is associated with prolonged survival. The risk of acute rejection does not appear to be increased with restrictive IS management. Therefore, strict reduction of IS should be an early intervention following diagnosis. In addition, surgical resection should be attempted, if technically feasible and oncologically meaningful.

Robotic assisted minimally invasive surgery has been implemented to overcome typical limitations of conventional laparoscopy such as lack of angulation, especially during creation of biliary and pancreatic anastomoses. With this retrospective analysis, we provide our experience with the first 101 consecutive robotic pancreatic resection performed at our center. Distal pancreatectomies (RDP, N = 44), total pancreatectomies (RTP, N = 3) and pancreaticoduodenectomies (RPD, N = 54) were included. Malignancy was found in 45.5% (RDP), 66.7% (RTP) and 61% (RPD). Procedure times decreased from the first to the second half of the cohort for RDP (218 min vs. 128 min, p = 0.02) and RPD (378 min vs. 271 min, p &lt, 0.001). Overall complication rate was 63%, 33% and 66% for RPD, RPT and RDP, respectively. Reintervention and reoperation rates were 41% and 17% (RPD), 33% and 0% (RTP) and 50% and 11.4% (RPD), respectively. The thirty-day mortality rate was 5.6% for RPD and nil for RTP and RDP. Overall complication rate remained stable throughout the study period. In this series, implementation of robotic pancreas surgery was safe and feasible. Final evaluation of the anastomoses through the median retrieval incision compensated for the lack of haptic feedback during reconstruction and allowed for secure minimally invasive resection and reconstruction.

Hintergrund Das Pankreasadenokarzinom kann aufgrund von Rezidivrate und Metastasierungstendenz als systemische Erkrankung verstanden werden, dessen kurativ intendierte Behandlung ein interdisziplinäres Vorgehen aus chirurgischer und systemischer Therapie in patientenindividualisierter Form voraussetzt. Im Rahmen dieser Promotion werden drei Säulen der aktuellen Pankreaschirurgie beleuchtet. Der Einfluss der neoadjuvanten Chemotherapie auf den postoperativen histopathologischen Status beim borderline-resektablen Pankreaskarzinom wurde mit dem Ziel untersucht, lokale beeinflussbare Tumorfaktoren zu identifizieren, die ursächlich für eine persistierende Rezidivtendenz sein können. Die zweite Säule der modernen Pankreaschirurgie stellt die differenzierte lokale Therapie dar. Hier wird auf die Rolle der subtotalen Pankreaslinksresektion mit simultaner Resektion des Truncus coeliacus im aktuellen Kontext eingegangen, um diese als differenzierte Therapiestrategie bei Patienten mit Tumoraffektion des Truncus coeliacus zu evaluieren. Die dritte Säule der modernen Pankreaschirurgie beinhaltet das Erkennen und Behandeln eingriffsspezifischer Komplikationen. Die nekrotisierende Pankreatitis des Restpankreas nach Pankreaskopfresektion wurde auf Risikofaktoren, Prädiktoren und zusätzlich einhergehende Komplikationen hin untersucht. Methoden Alle Auswertungen erfolgten retrospektiv. Abhängig von der Fragestellung wurde hierfür eine Kontrollgruppe anhand definierter Kriterien im Sinne einer Matched-Pair Vergleichsanalyse herangezogen. Die statistische Auswertung erfolgte mittels SPSS Version 25.0. Ein p-Wert unter 0.05 wurde als statistisch signifikant festgelegt. Ergebnisse und Schlussfolgerung Die Durchführung einer neoadjuvanten Chemotherapie beeinflusste in unserer Kohorte Nodalstatus und Lymphgefäßinfiltration beim borderline-resektablen Pankreaskarzinom signifikant. Übrige lokale Faktoren, z.B. Blutgefäß- oder Perineuralscheideninvasion, bleiben unbeeinflusst. Bei ansonsten vergleichbaren perioperativen Komplikationsraten traten in der Fallgruppe signifikant weniger schwerwiegende postoperative Pankreasfisteln (POPF) auf. Die subtotale Pankreaslinksresektion mit simultaner Resektion des Truncus coeliacus nach vorheriger angiografischer Vorbereitung ist im Vergleich zu Resektionen ohne Gefäßresektion eine sichere Therapieoption mit vergleichbarer perioperativer Komplikationsrate. In der Fallgruppe traten signifikant weniger schwerwiegende postoperative Pankreasblutungen (PPH) auf. In der Auswertung der Fälle nekrotisierender Pankreatitiden des Restpankreas nach Pankreasresektion sind signifikante Unterschiede in perioperativen Parametern, dem CRP-Verlauf und den SOFA-Scores, in Gesamtverweildauer und Verweildauer auf der Intensivstation zu erkennen. Sie ist eine histopathologische Diagnose, die sich in unserer Auswertung anhand klinischer Prädiktoren und Komplikationsraten signifikant von der nicht-nekrotisierenden Verlaufsform unterscheidet., Pancreatic ductal adenocarcinoma (PDAC) is a systemic disease especially due to distant metastasis and recurrence rates and although surgery is needed for a curative treatment, supplementation with systemic therapy strategies is mandatory. This doctoral thesis deals with three important columns in pancreatic surgery. The influence of neoadjuvant chemotherapy on the local postoperative histopathological tumour stage in borderline-resectable PDACs is evaluated to identify factors accountable for recurrence and to outline its value for other PDAC subtypes. Furthermore, the role of the subtotal distal pancreatectomy with simultaneous resection of the celiac axis compared to a subtotal distal pancreatectomy without resection of the celiac axis was assessed.. In the third column, the management of postoperative complications, a new complication entity, the postoperative necrotizing pancreatitis of the pancreatic remnant following pancreatic resections, was assessed for prediction factors and complication rates. Methods All evaluations were carried out retrospectively. Depending on the study design a matched control group was generated. Statistics were performed using SPSS version 25.0. A p-value lower than 0.05 was considered to be statistically significant. Results and Conclusion Patients treated with neoadjuvant chemotherapy showed a statistically significant lower rate of lymph node and lymphatic vessel invasion compared to those treated with upfront surgery. Other local histopathological factors such as perineural or vascular invasion remained unaffected. Perioperative complication rates were comparable and patients after neoadjuvant treatment showed a significant lower rate of severe postoperative pancreatic fistula (POPF). Therefore, neoadjuvant chemotherapy in the treatment of PDAC seems to be a feasible treatment option that enhances the postoperative local histopathological tumour stage. Subtotal distal pancreatectomy with simultaneous celiac axis resection after angiographic preparation appeared to be a safe treatment option with comparable complication rates. There were significantly fewer severe bleeding complications in the case group. Finally, the complication rate and feasible predictors for the occurrence of the postoperative necrotizing pancreatitis of the pancreatic remnant following pancreatic resections were evaluated. Preoperative CRP-levels, SOFA-scores as well as overall stay and stay at the intensive care unit differed significantly in patients with acute postoperative necrotizing pancreatitis of the pancreatic remnant. Although the necrotizing pancreatitis of the pancreatic remnant is diagnosed by a pathologist, clinical factors such as predictors and complication rates significantly differ from patients suffering from non-necrotizing pancreatitis of the pancreatic remnant.

Background and Objectives: An increasing number of patients (pts) with locally advanced pancreatic cancer (LAPC) are treated with an intensive neoadjuvant therapy to obtain a secondary curative resection. Only a certain number of patients benefit from this intention. The aim of this investigation was to identify prognostic factors which may predict a benefit for secondary resection. Materials and Methods: Survival time and clinicopathological data of pts with pancreatic cancer were prospective and consecutively collected in our Comprehensive Cancer Center Database. For this investigation, we screened for pts with primarily unresectable pancreatic cancer who underwent a secondary resection after receiving induction therapy in the time between March 2017 and May 2019. Results: 40 pts had a sufficient database to carry out a reliable analysis. The carbohydrate-antigen 19-9 (CA 19-9) level of the pts treated with induction therapy decreased by 44.7% from 4358.3 U/mL to 138.5 U/mL (p = 0.001). The local cancer extension was significantly reduced (p &lt, 0.001), and the Eastern Cooperative Oncology Group (ECOG) performance status was lowered (p = 0.03). The median overall survival (mOS) was 20 months (95% CI: 17.2&ndash, 22.9). Pts who showed a normal CA 19-9 level (&lt, 37 U/mL) at diagnosis and after neoadjuvant therapy or had a Body Mass Index (BMI) below 25 kg/m2 after chemotherapy had a significant prolonged overall survival (29 vs. 19 months, p = 0.02, 26 vs. 18 months, p = 0.04, 15 vs. 24 months, p = 0.01). Pts who still presented elevated CA 19-9 levels &gt, 400 U/mL after induction therapy did not profit from a secondary resection (24 vs. 7 months, p &lt, 0.001). Nodal negativity as well as the performance of an adjuvant therapy lead to better mOS (25 vs. 15 months, p = 0.003, 10 vs. 25 months, p &lt, 0.001). Conclusion: The pts in our investigation had different benefits from the multimodal treatment. We identified the CA 19-9 level at time of diagnosis and after neoadjuvant therapy as well as the preoperative BMI as predictive factors for overall survival. Furthermore, diagnostics of presurgical nodal status should gain more importance as nodal negativity is associated with better outcome.

The implementation of a pancreatico-enteric anastomosis following open single stage pancreaticoduodenectomy (PD) is still associated with the most threatening complications in modern pancreatic surgery, such as postoperative pancreatic fistula (POPF), postpancreatectomy haemorrhage (PPH), delayed gastric emptying (DGE), intraabdominal abscesses and related mortality. With this study, we introduce Charité-PG, a new dorsal incision only invagination type pancreatogastrostomy (dioPG) for the restoration of the pancreatic remnant following PD, and compare it to a PG requiring ventral gastrotomy (vgPG). A total of 49 consecutive patients, who underwent reconstruction via dioPG, and 92 consecutive patients, who underwent restoration via vgPG, were identified from our prospective database and further reviewed for perioperative parameters, complication rates, mortality and follow-up. The percentage of overall complications (p = 0.301), as well as the 30-day mortality rate (p = 0.725) and survival (p = 0.543), were comparable in both groups. The operation time in the dioPG group was significantly shorter (p = 0.04), and patients in this group developed substantially fewer rates of DGE (p = 0.036). We provide a feasible and safe technique for restoration following PD via our novel dioPG, causing fewer cases of DGE. Nevertheless, pancreatico-enteric anastomoses require expertise and experience.

Successful implementation of left ventricular assist devices lead to a prolonged survival in patients with chronic terminal heart failure. Thus, patients with pre-existing left ventricular assist devices with abdominal comorbidities requiring abdominal surgery, e.g. for malignancy, are upcoming issues. We carried out a major liver resection for hepatocellular carcinoma in a patient with pre-existing left ventricular assist device. The importance of this case report is that it outlines the significance of oncologic resections in patients with left ventricular assist devices as an upcoming issue and provides an interdisciplinary approach.