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Background: Pancreatic Ductal Adenocarcinoma (PDAC) primarily affects older individuals with diminished physiological reserves. The Modified 5-Item Frailty Index (mFI-5) is a novel risk stratification tool proposed to predict postoperative morbidity and mortality. This study aimed to validate the mFI-5 for predicting surgical outcomes in patients undergoing pancreatoduodenectomy (PD) for PDAC. Methods: Our retrospective PDAC database included patients who underwent PD between 2014 and 2023. Patients were stratified by mFI-5 scores (0 best − 5 worst), which assess preoperative CHF, diabetes mellitus, history of COPD or pneumonia, functional health status, and hypertension requiring medication. Associations between mFI-5 scores and outcomes, including postoperative complications and mortality, were analyzed using logistic regression, Cox proportional hazards models, and Kaplan-Meier survival analysis. Results: Among 250 PDAC patients undergoing PD, 142 (56.8%) had mFI-5 scores ≤ 1, and 25 (10%) had scores ≥ 3. No patients had scores > 4. Higher mFI-5 scores correlated with older age (p < 0.001) and tobacco use (p = 0.036). Multivariate analysis identified age (RR 1.02, p = 0.038), ASA class (ASA III; RR 2.61, p < 0.001; ASA IV; RR 2.63, p = 0.026), and moderate alcohol consumption (RR 0.56, p = 0.038) as frailty predictors. An mFI-5 score > 2 independently associated with higher mortality (HR 2.08, p = 0.026). Median overall survival was significantly lower for patients with mFI-5 scores > 2 than for those with scores ≤ 2 (21.3 vs. 42.1 months, p = 0.022). Conclusions: The mFI-5 is a valuable tool for predicting postoperative morbidity and mortality in PDAC patients undergoing PD. Integrating frailty assessment into preoperative evaluations can enhance patient selection and surgical outcomes. Future research should focus on incorporating frailty assessments into surgical planning and patient management to improve outcomes in this vulnerable population. [ABSTRACT FROM AUTHOR]

Purpose: Pancreatic ductal adenocarcinoma (PDAC) has been shown to have a lower incidence in patients with blood group O. It is currently uncertain if patients with group O have a better prognosis after pancreatectomy. This study assessed the overall survival (OS) and disease-free survival (DFS) of PDAC patients who underwent upfront pancreatoduodenectomy based on ABO blood groups. Methods: A cross-sectional study was performed including patients from two university centers. All consecutive head PDAC patients who underwent upfront pancreatoduodenectomy from 2000 to 2016 were included. OS and DFS were compared between blood groups A, B, AB, and O using Kaplan-Meier curves and log-rank tests. Results: A total of 438 patients were included (215 women, median age 67). Pre- and intraoperative details were comparable between all subgroups. Median OS did not differ between the four blood groups (A: 23 months, 95% CI 18–28; B: 32, 95% CI 20–44; AB: 37, 95% CI 18–56 and O: 26, 95% CI 20–32, p = 0.192). Median DFS were also similar (A: 19 months, 95% CI 15–23; B: 26, 95% CI 19–33; AB: 35, 95% CI 15–55 and O: 22, 95% CI 15–29, p = 0.441). There was no OS difference between O and non-O groups (median: 26 months, 95% CI 20–33 vs. 25 months, 95% CI 20–30, p = 0.773). On multivariable analysis blood groups were not prognostic of OS. Only lymph node involvement, tumor differentiation, and adjuvant chemotherapy were independent prognostic factors. Conclusion: OS and DFS were similar between all four blood groups after pancreatoduodenectomy. Independent predictors of OS were associated with tumor characteristics and adjuvant treatment. [ABSTRACT FROM AUTHOR]

Purpose: The necessity of routine drain placement in pancreatic resections is controversial. Some randomized controlled trials have shown that the omission of drainage is safe for some patients, whereas reintervention rates and mortality rates are substantial for others. The present study aimed to assess fistula-associated outcomes in the setting of routine drain placement and drain irrigation on demand. Methods: Between 01/2017 and 12/2022, perioperative and outcome data from patients who underwent consecutive pancreatoduodenectomies (PD, n = 253) or distal pancreatectomies (DP, n = 72) were prospectively collected in the electronic StuDoQ database and analysed. All patients underwent intraoperative drain placement. Drains were removed starting at postoperative day 2 in PD or at day 5 in DP after testing for amylase concentration. In case of high amylase levels or macroscopically suspicious pancreatic fistulas, drain irrigation was started. Nondrained fluid collections underwent percutaneous radiologic or transluminal endoscopic evacuation. Results: Clinically relevant pancreatic fistulas were detected in 53 of 325 patients (POPF grade B 16.3%, grade C 1.2%). 43.3% of those had drain irrigation. Additional interventional or endoscopic drainage was necessary in 14 and 5 patients, respectively (overall 5.8%), and were observed in 4.0% of patients with PD and in 12.5% with DP (p = 0.009). Delayed fistula-associated postpancreatectomy haemorrhage (PPH) was present in 1.2% (4/325) of patients. The fistula- and delayed PPH-associated reoperation rate was 1.5% (5/325). The 30-day and in-hospital mortality rates were both 1.5% (5/325), and the rate of fistula-associated mortality was 0.6% (2/325). The overall 90-day mortality rate was 4.5%. Conclusions: In pancreatectomies, a standardized drainage protocol including on-demand drain irrigation results in very low fistula-associated morbidity and mortality and an infrequent need for interventional or surgical reintervention as compared to previously published drainage studies. [ABSTRACT FROM AUTHOR]

Background: There are several reports on the safety and feasibility of pancreatoduodenectomy (PD) without reconstruction of the small remnant pancreas. However, a few studies have explored central pancreatectomy (CP) for non-reconstructed small remnant pancreases after PD. This study presents a case of CP without pancreatic reconstruction after PD. Case presentation: A 58-year-old man with cerebral palsy underwent PD for distal cholangiocarcinoma. Three years postoperatively, a 12-mm tumor was detected in the remnant pancreatic body and diagnosed as a pancreatic neuroendocrine neoplasm. Surgical resection was performed, because the tumor was enlarged and chemotherapy resistant. The afferent loop with pancreatojejunostomy anastomosis was dissected, and CP, including pancreatojejunostomy anastomosis, was performed. Given the remnant pancreas was hard and atrophic, the pancreatic tail was transected using a stapler without reconstructing the small remnant pancreas. The patient experienced no postoperative complications including postoperative pancreatic fistula, and the endocrine function of the pancreas was preserved. Conclusions: We present a case of remnant pancreatic CP that did not require reconstruction after PD. Preservation of the small remnant pancreas without reconstruction during CP may be feasible to maintain endocrine function in select patients after PD. [ABSTRACT FROM AUTHOR]

Purpose: Locally advanced pancreatic ductal adenocarcinoma (PDAC) with an unreconstructible superior mesenteric vein (SMV) invasion is one of the criteria of unresectability in the National Comprehensive Cancer Network guidelines. Advances in chemotherapy have improved downstaging and conversion surgery outcomes, thereby broadening surgical options for locally advanced PDAC. However, operations for PDAC with an unreconstructible SMV is less well-documented. If the collateral route is well-developed and can be preserved or reconstructed, SMV resection can be performed without reconstruction. In this paper, we detail our surgical technique and the outcomes for patients undergoing pancreatoduodenectomy with SMV resection and non-reconstruction (PD-SMVR-NR). Methods: All consecutive patients with pancreatic head cancer who underwent PD at Juntendo University Hospital, Japan, between January 2019 and December 2022 were evaluated from a prospectively maintained preoperative database. Demographic data, clinical history, operative record, morbidity, mortality, and pathologic data were reviewed. Results: Over four years at our Institute, 161 patients with pancreatic head cancer underwent PD, and 86 of these patients underwent PD with portal vein (PV) or SMV resection. There were three patients who underwent PD-SMVR-NR. Each patient had well-developed collateral vessels bypassing the obstructed segment of the SMV. All three patients had no hospital mortality with acceptable complications (Clavien-Dindo grade 2). Two patients achieved R0 resection. Conclusion: By understanding the hemodynamics of venous flow and preserving collateral vessels, especially the superior right colic vein arcade and porto-mesenterico-splenic confluence, pancreatoduodenectomy with superior mesenteric vein resection and non-reconstruction can be performed safely. [ABSTRACT FROM AUTHOR]

Introduction: Cholangiocarcinoma during pregnancy is an extremely rare entity with poor prognosis. Limited data are available regarding the diagnosis, progression, and pregnancy-related outcomes. Case Presentation: We present a case of mid-to-distal cholangiocarcinoma diagnosed by endosonographically guided biopsy during pregnancy at 15 weeks of gestation. Pregnancy termination was considered but based on multidisciplinary team and shared decision-making, surgery was performed during pregnancy. The patient underwent pancreatoduodenectomy with radical resection at 17 weeks of gestation. The postoperative period was complicated by a grade B postoperative pancreatic fistula treated by antibiotics only. At 39 weeks of gestation, a cesarean section was performed and a healthy boy was delivered. Conclusion: Decision-making on whether to perform a pancreatoduodenectomy in pregnant patients is challenging. This case report is the first to report on successful pancreatoduodenectomy during pregnancy for extrahepatic cholangiocarcinoma. Moreover, this case highlights the second trimester as favorable period for surgical intervention and the importance of close follow-up and diagnostic assessment of pregnant patients with unexplained and persistent abnormal liver function tests. [ABSTRACT FROM AUTHOR]

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

Aim: The aim of this study was to clarify the significance of blood culture testing in the postoperative period of pancreatoduodectomy (PD), a highly invasive surgery. Methods: Rates of blood culture sampling and positivity were investigated for febrile episodes (FEs) in patients who underwent PD (2016–2021). FEs were defined as body temperature of 38.0°C or higher occurring on or after the 4th postoperative day. Fever origin was diagnosed retrospectively, and FEs were classified as pancreatic fistula (PF)‐related or PF‐unrelated FEs. Factors correlated with blood culture positivity were explored. Results: Among 339 patients who underwent PD, 99 experienced 202 FEs. Blood culture testing was performed on 160 FEs occurring in 89 patients. The sampling and positivity rates were 79.2% and 17.5%, respectively, per episode and 89.9% and 28.1%, respectively, per patient. Thirty‐six FEs were classified as PF‐related and 124 were classified as PF‐unrelated FEs. The blood culture positivity rate was significantly lower in PF‐related vs. PF‐unrelated FEs (1/36 vs. 27/124, respectively, p = 0.006). The blood culture positivity rate was significantly higher in patients with cholangitis, catheter‐related blood stream infection, and urinary tract infection than PF‐related FEs. Multivariate analysis showed that blood culture positivity was negatively associated with PF‐related FEs and positively associated with accompanying symptoms of shivering, Pitt Bacteremia Score, and preoperative biliary drainage. Conclusions: Patients who underwent PD showed relatively high blood culture positivity rates. Based on these results, it may be possible to distinguish PF‐related and ‐unrelated FEs. [ABSTRACT FROM AUTHOR]

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

Purpose: To determine the causes of benign hepaticojejunostomy strictures (BHSs) after pancreaticoduodenectomy (PD) and the outcome of endoscopic retrograde cholangiography (ERC) treatment for BHSs. Methods: A total of 175 patients who underwent PD between January 2013 and December 2020 and who were followed up for at least 1 year were included. Preoperative data, operative outcomes, and postoperative courses were compared between the BHS group and the group of patients who did not develop stenosis during follow-up (non-BHS group). The course of treatment in the BHS group was also examined. Results: BHS occurred in 13 of 175 patients (7.4%). Multivariate analysis of the BHS and non-BHS groups revealed that male sex (OR; 3.753, 95% CI; 1.029–18.003, P = 0.0448) and a preoperative bile duct diameter less than 8.8 mm (OR; 7.51, 95% CI; 1.75–52.40, P = 0.0053) were independent risk factors for the development of BHS. In the BHS group, all patients underwent ERC using enteroscopy. The success rate of the ERC approach to the bile duct was 92.3%. Plastic stents were inserted in 6 patients, and metallic stents were inserted in 3 patients. The median observation period since the last ERC was 17.9 months, and there was no recurrence of stenosis in any of the 13 patients. Conclusions: Patients with narrow bile ducts are at greater risk of BHS after PD. Recently, BHS after PD has been treated with ERC-related procedures, which may reduce the burden on patients. [ABSTRACT FROM AUTHOR]

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

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

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

Aim Patients and Methods Results Conclusion This study aims to identify the cut‐off drain amylase (DA) values on the first, third, and fifth post‐operative days (POD1‐DA, POD3‐DA, and POD5‐DA) that are correlated with clinically relevant post‐operative pancreatic fistula (CR‐POPF).All data were retrospectively collected from patients who underwent pancreatectomy at the Department of Surgery, Phramongkutklao Hospital, from January 2015 to December 2023. A total of 195 patients were included in the study.A total of 195 patients were analysed, including 35 patients with CR‐POPF, with a mean age of 60.84 years. There were no statistically significant differences in demographic data between patients with CR‐POPF and those without. In addition, no statistical differences were observed in pancreatic duct diameter (3 mm vs 2 mm), operative time (468.9 min vs 500.29 min), or blood loss (600 mL vs 600 mL) between the CR‐POPF and no CR‐POPF groups. Length of hospital stays was longer in the CR‐POPF group compared with the no CR‐POPF group (33 days vs 11 days, P = .001). In addition, the CR‐POPF group had significantly higher rates of post‐operative pancreatic haemorrhage (20% vs 2.5%), bile leakage (5.71% vs 0%), delayed gastric emptying (45.71% vs 3.13%), wound complications (34.29% vs 5%), and mortality (17.14% vs 1.88%) compared with the no CR‐POPF group. The optimal cut‐off values for CR‐POPF were 1313 U/L on day 1 (D1; area under the curve [AUC] 0.72, 95% confidence interval [CI] 0.65–0.84, sensitivity 91%, specificity 52%), 492 U/L on D3 (AUC 0.77, 95% CI 0.70–0.83, sensitivity 91%, specificity 64%), and 360 U/L on D5 (AUC 0.65, 95% CI 0.52–0.75, sensitivity 69%, specificity 61%). There were no significant perioperative factors associated with CR‐POPF in our study.DA levels of 1313, 492, and 360 U/L on post‐operative D1, D3, and D5, respectively, were associated with CR‐POPF. Drain removal can be safely performed without the risk of CR‐POPF when these levels are met. [ABSTRACT FROM AUTHOR]

Objective To explore the prevention and treatment strategies for pancreatic fistula and pancreatic fistula combined with hemorrhage after pancreaticoduodenectomy. Methods We retrospectively reviewed 90 cases of pancreaticoduodenectomy at Guangdong Provincial People's Hospital from August 2019 to December 2022. According to whether postoperative pancreatic fistula occurred, the 90 patients were divided into a postoperative pancreatic fistula group (n = 35) and a postoperative non-pancreatic fistula group (n = 55). Among the 35 patients with postoperative pancreatic fistula, they were further categorized into two subgroups based on the presence of hemorrhage: the pancreatic fistula with hemorrhage group (n = 10) and the pancreatic fistula without hemorrhage group (n = 25). Chi-square test or Fisher's exact test was used for univariate analysis. Variables with statistical differences were selected for stepwise regression variable screening. Multivariate Logistic regression analysis was used to determine the independent risk factors for the occurrence of pancreatic fistula and postoperative pancreatic fistula with hemorrhage. Results All 90 patients successfully completed the pancreaticoduodenectomy. The incidence of postoperative pancreatic fistula was 38.9% (35/90). Significant differences were observed in pancreatic duct diameter (P = 0.013), intraoperative blood loss (P = 0.045), anastomosis type (P = 0.045), and residual pancreatic texture (P = 0.10) between the two groups (P < 0.05). Multivariate logistic regression analysis revealed that soft pancreas texture, pancreatic duct diameter < 3 mm, intraoperative blood loss ≥ 300 mL, and pancreatic-ojejunostomy were independent risk factors for postoperative pancreatic fistula. Among patients with postoperative pancreatic fistula, multivariate logistic regression analysis identified pancreatic fistula volume > 100 mL and duration of postoperative pancreatic fistula > 7 days as independent risk factors for hemorrhage. Conclusions The risk of pancreatic fistula after pancreatoduodenectomy is relatively high. Attention to preoperative pancreatic duct diameter and standardized evaluation of pancreatic texture can help identify postoperative pancreatic fistula. Careful hemostasis during operation and avoidance of early postoperative hemorrhage can reduce the incidence of grade B and C pancreatic fistulas. Patients with pancreatic fistula should be warned of the occurrence of combined hemorrhage when the fistula volume is greater than 100ml and the duration of postoperative pancreatic fistula is greater than 7 days. [ABSTRACT FROM AUTHOR]

Pancreatoduodenectomy is the most appropriate technique for the treatment of periampullary tumors. In the past, this procedure was associated with high mortality and morbidity, but with improvements in patient selection, anesthesia, and surgical technique, mortality has decreased to less than 5%. However, morbidity remains increased due to various complications such as delayed gastric emptying, bleeding, abdominal collections, and abscesses, most of which are related to the pancreatojejunostomy leak. Clinically relevant postoperative pancreatic fistula is the most dangerous and is related to other complications including mortality. The incidence of postoperative pancreatic fistula ranges from 5–30%. Various techniques have been developed to reduce the severity of pancreatic fistulas, from the use of an isolated jejunal loop for pancreatojejunostomy to binding and invagination anastomoses. Even total pancreatectomy has been considered to avoid pancreatic fistula, but the late effects of this procedure are unacceptable, especially in relatively young patients. Recent studies on the main techniques of pancreatojejunostomy concluded that duct-to-mucosa anastomosis is advisable, but no technique eliminates the risk of pancreatic fistula. The purpose of this study is to highlight technical details and tips that may reduce the severity of pancreatic fistula after pancreatojejunostomy during open or minimally invasive pancreatoduodenectomy. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy. Preoperative factors are limited and controversial. This study aims to identify associated factors related to this complication in the Colombian population. Methods: A retrospective review of a prospectively collected database was conducted. All patients over 18 years of age who underwent pancreaticoduodenectomy were included. Associations with DGE syndrome were evaluated with logistic regression analysis, Odds ratio, and b-coefficient were provided when appropriate. Results: 205 patients were included. Male patients constituted 54.15% (n = 111). 53 patients (25.85%) were diagnosed with DGE syndrome. Smoking habit (OR 17.58 p 0.00 95% CI 7.62–40.51), hydromorphone use > 0.6 mg/daily (OR 11.04 p 0.03 95% CI 1.26–96.66), bilirubin levels > 6 mg/dL (OR 2.51 p 0.02 95% CI 1.12–5.61), and pancreatic fistula type B (OR 2.72 p 0.02 CI 1.74–10.00). Discussion: Smoking history, opioid use (hydromorphone > 0.6 mg/Daily), type B pancreatic fistula, and bilirubin levels > 6 mg/dL should be considered as risk factors for DGE. [ABSTRACT FROM AUTHOR]

Arterial variations in the liver's blood supply play a pivotal role in the success of pancreatoduodenectomy (PD), impacting both its technical execution and oncological outcomes. Among these variations, a common hepatic artery arising from the superior mesenteric artery (SMA) occurs in about 3% of cases. An exceptionally rare variation is the intrapancreatic common hepatic artery (IPCHA). Preserving or reconstructing the IPCHA is vital during PD to prevent liver and biliary necrosis. Particularly for cases of pancreatic cancer with high rates of intrapancreatic perineural spread, preserving IPCHA without compromising radicality presents challenges. We present a detailed report of the technique used for PD in the presence of IPCHA. Surgical technique details include a pylorus-preserving PD with the Cattell–Braasch maneuver, an artery-first approach, and meticulous dissection using "cold" scissors. We emphasize the importance of strategic surgical planning based on high-quality imaging studies, underscoring the need for pancreatic surgeons to be proficient in managing variations in visceral vessels. In conclusion, this case underscores the significance of navigating rare arterial variations in liver supply during PD, highlighting the necessity for meticulous surgical planning and execution. [ABSTRACT FROM AUTHOR]

Postoperative pancreatic fistula (POPF) is one of the most feared and common complications following pancreatoduodenectomies. This study aims to evaluate the performance of different scales in predicting POPF using magnetic resonance imaging (MRI), including estimation of the pancreatic duct diameter, pancreatic texture, main duct index, relation to the portal vein, and intra-abdominal fat thickness. A retrospective diagnostic test study was designed. Between January 2017 and December 2021, 133 pancreatoduodenectomies were performed at our institution. The performance for predicting overall POPF and clinically relevant POPF (CR-POPF) was evaluated using a receiver operating characteristic (ROC) curve. A total of 96 patients were included in the study, of whom 26 patients experienced overall POPF, and 8 patients had CR-POPF. When analyzing the predictive value of each of the different scores applied, the Birmingham score showed the highest performance for predicting overall POPF and CR-POPF with an AUC (area under the curve) of 0.815 (95 % CI 0.725–0.906) and 0.813 (0.679–0.947), respectively. The Birmingham scale demonstrated the highest predictive performance for POPF. It is a simple scale with only two variables that can be obtained preoperatively using MRI. Based on these results, we recommend its use in patients undergoing pancreatoduodenectomy. [ABSTRACT FROM AUTHOR]

Introduction: Cholangiocarcinoma during pregnancy is an extremely rare entity with poor prognosis. Limited data are available regarding the diagnosis, progression, and pregnancy-related outcomes. Case Presentation: We present a case of mid-to-distal cholangiocarcinoma diagnosed by endosonographically guided biopsy during pregnancy at 15 weeks of gestation. Pregnancy termination was considered but based on multidisciplinary team and shared decision-making, surgery was performed during pregnancy. The patient underwent pancreatoduodenectomy with radical resection at 17 weeks of gestation. The postoperative period was complicated by a grade B postoperative pancreatic fistula treated by antibiotics only. At 39 weeks of gestation, a cesarean section was performed and a healthy boy was delivered. Conclusion: Decision-making on whether to perform a pancreatoduodenectomy in pregnant patients is challenging. This case report is the first to report on successful pancreatoduodenectomy during pregnancy for extrahepatic cholangiocarcinoma. Moreover, this case highlights the second trimester as favorable period for surgical intervention and the importance of close follow-up and diagnostic assessment of pregnant patients with unexplained and persistent abnormal liver function tests.

Abstract Aim The aim of this study was to clarify the significance of blood culture testing in the postoperative period of pancreatoduodectomy (PD), a highly invasive surgery. Methods Rates of blood culture sampling and positivity were investigated for febrile episodes (FEs) in patients who underwent PD (2016–2021). FEs were defined as body temperature of 38.0°C or higher occurring on or after the 4th postoperative day. Fever origin was diagnosed retrospectively, and FEs were classified as pancreatic fistula (PF)‐related or PF‐unrelated FEs. Factors correlated with blood culture positivity were explored. Results Among 339 patients who underwent PD, 99 experienced 202 FEs. Blood culture testing was performed on 160 FEs occurring in 89 patients. The sampling and positivity rates were 79.2% and 17.5%, respectively, per episode and 89.9% and 28.1%, respectively, per patient. Thirty‐six FEs were classified as PF‐related and 124 were classified as PF‐unrelated FEs. The blood culture positivity rate was significantly lower in PF‐related vs. PF‐unrelated FEs (1/36 vs. 27/124, respectively, p = 0.006). The blood culture positivity rate was significantly higher in patients with cholangitis, catheter‐related blood stream infection, and urinary tract infection than PF‐related FEs. Multivariate analysis showed that blood culture positivity was negatively associated with PF‐related FEs and positively associated with accompanying symptoms of shivering, Pitt Bacteremia Score, and preoperative biliary drainage. Conclusions Patients who underwent PD showed relatively high blood culture positivity rates. Based on these results, it may be possible to distinguish PF‐related and ‐unrelated FEs.

Abstract Purpose To determine the causes of benign hepaticojejunostomy strictures (BHSs) after pancreaticoduodenectomy (PD) and the outcome of endoscopic retrograde cholangiography (ERC) treatment for BHSs. Methods A total of 175 patients who underwent PD between January 2013 and December 2020 and who were followed up for at least 1 year were included. Preoperative data, operative outcomes, and postoperative courses were compared between the BHS group and the group of patients who did not develop stenosis during follow-up (non-BHS group). The course of treatment in the BHS group was also examined. Results BHS occurred in 13 of 175 patients (7.4%). Multivariate analysis of the BHS and non-BHS groups revealed that male sex (OR; 3.753, 95% CI; 1.029–18.003, P = 0.0448) and a preoperative bile duct diameter less than 8.8 mm (OR; 7.51, 95% CI; 1.75–52.40, P = 0.0053) were independent risk factors for the development of BHS. In the BHS group, all patients underwent ERC using enteroscopy. The success rate of the ERC approach to the bile duct was 92.3%. Plastic stents were inserted in 6 patients, and metallic stents were inserted in 3 patients. The median observation period since the last ERC was 17.9 months, and there was no recurrence of stenosis in any of the 13 patients. Conclusions Patients with narrow bile ducts are at greater risk of BHS after PD. Recently, BHS after PD has been treated with ERC-related procedures, which may reduce the burden on patients.

Abstract Background Pancreatic head cancer patients who undergo pancreatoduodenectomy (PD) often experience disease recurrence, frequently associated with a positive margin status (R1). Total mesopancreas excision (TMpE) has emerged as a potential approach to increase surgical radicality and minimize locoregional recurrence. However, its effectiveness and safety remain under evaluation. Methods We conducted a systematic review and meta-analysis to synthesize current evidence on TMpE outcomes. A systematic search of MEDLINE, EMBASE, Cochrane, and Web of Science databases was conducted up to March 2024 to identify studies comparing TMpE with standard pancreatoduodenectomy (sPD). The risk ratio (RR) or mean difference (MD) was pooled using a random effects model. Results From 452 studies identified, 9 studies with a total of 738 patients were included, with 361 (49%) undergoing TMpE. TMpE significantly improved the R0 resection rate (RR 1.24; 95% CI 1.11–1.38; P

Analysis of data published in the modern literature on the role of the number of functioning acinar cells of the pancreas as a prognostic marker of the development of pancreatic fistula. The search for sources was carried out in the systems Clinicaltrials.gov, PubMed, Medline, NCCN, Scopus, Elibrary. In writing the literature review, 52 sources published from 2004 to 2022 were used. Included are studies reflecting the importance of functioning acinar cells at the edge of pancreatic resection, as well as other factors associated with the development of pancreatic fistula and other post-resection complications. A large number of acinar cells (40%) and a low collagen content (15%) in the edge of pancreatic resection significantly correlates with the development of pancreatic fistula. The content of adipose tissue in the edge of pancreatic resection showed no connection with the development of pancreatic fistula and other complications after surgery. Palpatory assessment of the structure of the pancreatic parenchyma is subjective and can lead to erroneous interpretation and adoption of inadequate tactics of preventive measures. Intraoperative counting of acinuses at the edge of pancreatic resection is easy to use, while not yielding to more complex methods for assessing the risk of post-resection complications and can be recommended as a routine method for predicting the occurrence of pancreatic fistula

Background. The main method of treatment of desmoid fibromatosis is surgical, especially in patients with symptomatic disease or in cases of progression during the Look and Stay period. Due to the rarity of the disease, different localization, unpredictability of the clinical course, the lack of generally accepted clear criteria for choosing a treatment method and/or a sequence of treatment methods, the determination of prognostic criteria for the course of the disease is of great scientific and practical interest. Aim. To study the immediate and long-term outcomes of surgical treatment in patients with retroperitoneal and abdominal desmoid fibromatosis. Materials and methods. The study analyzed the data of 121 patients with histologically verified retroperitoneal and abdominal desmoid fibromatosis who underwent surgical treatment at the Blokhin National Medical Research Center of Oncology from 1999 to 2022. Results. In 89% of cases, desmoid tumors are resectable; however, resections of adjacent organs are often required to remove the tumor mass completely. The frequency of combined interventions in the abdominal and retroperitoneal groups was 7.0 and 60.4%, respectively. Tumor cells along the edge of the incision are identified in 15.8% of patients, including 10% of patients with macroscopically detectable residual tumors. Surgical treatment of patients with desmoid tumors is associated with an acceptable complication rate and provides high rates of overall and relapse-free survival. Risk factors for disease-free survival of operated patients are retroperitoneal localization, multicentric tumor growth, and R2 category. Conclusion. The treatment of patients with retroperitoneal and abdominal desmoid tumors should be carried out in specialized clinics with sufficient experience in performing surgical interventions, including combined ones. The treatment approach in patients with desmoid tumors should be selected by a multidisciplinary team based on personalized oncological and functional prognoses in accordance with the prognostic risk groups.

Left-sided portal hypertension (LSPH) causes varices and splenomegaly due to splenic vein issues. Colonic varices are rare and lack standardized treatment. We report the successful treatment of colonic varices caused by LSPH, by addressing both the afferent and efferent veins. A 70-year-old man with distal cholangiocarcinoma had surgery without splenic vein resection, leading to proximal splenic vein stenosis and varices at multiple locations. Percutaneous transhepatic splenic venography revealed that collateral veins flowed into the ascending colonic varices and returned to the portal vein. Complete thrombosis of the varices was achieved by injecting sclerosants and placing coils in both the afferent and efferent veins. The procedure was safe and effective, with no variceal recurrence. This approach provides a minimally invasive option for treating colonic varices associated with LSPH.

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

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

Objective: Whole-course nutrition management (WNM) has been proven to improve outcomes and reduce complications. We conducted this randomized controlled trial to validate its effectiveness in patients undergoing pancreatoduodenectomy (PD). Methods: From 1 December 2020, to 30 November 2023, this single-center randomized clinical trial was conducted at the Department of Hepatobiliopancreatic Surgery in a major hospital in Beijing, China. Participants who were undergoing PD were enrolled and randomly allocated to either the WNM group or the control group. The primary outcome was the incidence of postoperative complications. Subgroup analysis in patients who were at nutritional risk was performed. Finally, a 6-month follow-up was conducted and the economic benefit was evaluated using an incremental cost-effectiveness ratio (ICER). Results: A total of 84 patients were randomly assigned (1:1) into the WNM group and the control group. The incidences of total complications (47.6% vs. 69.0%, P= 0.046), total infections (14.3% vs. 33.3%, P=0.040), and abdominal infection (11.9% vs. 31.0%, P= 0.033) were significantly lower in the WNM group. In the subgroup analysis of patients at nutritional risk, 66 cases were included (35 cases in the WNM group and 31 cases in the control group). The rate of abdominal infection (11.4% vs. 32.3%, P =0.039) and postoperative length of stay (23.1 ± 10.3 vs. 30.4 ± 17.2, P=0.046) were statistically different between the two subgroups. In the 6-month follow-up, more patients reached the energy target in the WNM group (97.0% vs. 79.4%, P=0.049) and got a higher daily energy intake (1761.3 ± 339.5 vs. 1599.6 ± 321.5, P=0.045). The ICER suggested that WNM saved 31 511 Chinese Yuan (CNY) while reducing the rate of total infections by 1% in the intention-to-treat (ITT) population and saved 117 490 CNY in patients at nutritional risk, while WNM saved 31 511 CNY while reducing the rate of abdominal infections by 1% in the ITT population and saved 101 359 CNY in patients at nutritional risk. Conclusion: In this trial, whole-course nutrition management was associated with fewer total postoperative complications, total and abdominal infections, and was cost-effective, especially in patients at nutritional risk. It seems to be a favorable strategy for patients undergoing PD. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The mini-fluid challenge (MFC), which assesses the change in stroke volume index (SVI) following the administration of 100 mL of crystalloids, and the short-time low positive end-expiratory pressure (PEEP) challenge (SLPC), which evaluates the temporary reduction in SVI due to a PEEP increment, are two functional hemodynamic tests used to predict fluid responsiveness in the operating room. However, SLPC has not been assessed in patients undergoing abdominal surgery, and there is no study comparing these two methods during laparotomy. Therefore, we aimed to compare the SLPC and MFC in patients undergoing open pancreaticoduodenectomy. PATIENTS AND METHODS: All patients received a standard hemodynamic management. The study protocol evaluated the percentage change in SVI following the application of an additional 5 cm- H2O PEEP (SVI%-SLPC) and the infusion of 100 mL crystalloid (SVI%-MFC). Challenges that resulted in an increase of more than 15% in SVI after the 500 ml of fluid loading were classified as positive challenges (PC). Areas under the receiver operating characteristics curves (ROC AUCs) were used for the comparison of the methods. RESULTS: Thirty-three patients completed the study with 94 challenges. Fifty-five (58.5%) of them were PCs. The ROC AUC of SVI%-MFC was observed to be significantly higher than that of SVI%-SLPC (0.97 vs. 0.64, p < 0.001). The best cut-off value for SVI%-MFC was 5.6%. If we had stopped the bolus fluid administration when SVI%-MFC = 5% was observed (lower limit of the gray zone), we would have postponed the fluid loading in 35 (89.7%) of 39 negative challenges. The amount of fluid deferred would have corresponded to up to 40% of the total fluid given. CONCLUSIONS: SVI%-MFC predicts fluid responsiveness with high diagnostic performance and is better than SVI%-SLPC in patients undergoing open pancreatoduodenectomy. Additionally, the use of SVI%-MFC has the potential to defer up to 40% of the total fluid given. [ABSTRACT FROM AUTHOR]

Background: Pancreatoduodenectomy (PD) has a considerable surgical risk for complications and late metabolic morbidity. Parenchyma-sparing resection of benign tumors has the potential to cure patients associated with reduced procedure-related short- and long-term complications. Materials and Methods: Pubmed, Embase, and Cochrane libraries were searched for studies reporting surgery-related complications following PD and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. A total of 38 cohort studies that included data from 1262 patients were analyzed. In total, 729 patients underwent DPPHR and 533 PD. Results: Concordance between preoperative diagnosis of benign tumors and final histopathology was 90.57% for DPPHR. Cystic and neuroendocrine neoplasms (PNETs) and periampullary tumors (PATs) were observed in 497, 89, and 31 patients, respectively. In total, 34 of 161 (21.1%) patients with intraepithelial papillar mucinous neoplasm exhibited severe dysplasia in the final histopathology. The meta-analysis, when comparing DPPHRt and PD, revealed in-hospital mortality of 1/362 (0.26%) and 8/547 (1.46%) patients, respectively [OR 0.48 (95% CI 0.15–1.58); p = 0.21], and frequency of reoperation of 3.26 % and 6.75%, respectively [OR 0.52 (95% CI 0.28–0.96); p = 0.04]. After a follow-up of 45.8 ± 26.6 months, 14/340 patients with intraductal papillary mucinous neoplasms/mucinous cystic neoplasms (IPMN/MCN, 4.11%) and 2/89 patients with PNET (2.24%) exhibited tumor recurrence. Local recurrence at the resection margin and reoccurrence of tumor growth in the remnant pancreas was comparable after DPPHR or PD [OR 0.94 (95% CI 0.178–5.34); p = 0.96]. Conclusions: DPPHR for benign, premalignant neoplasms provides a cure for patients with low risk of tumor recurrence and significantly fewer early surgery-related complications compared with PD. DPPHR has the potential to replace PD for benign, premalignant cystic and neuroendocrine neoplasms. [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]

Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple procedure or pylorus-preserving pancreatoduodenectomy (PD). However, when performed for treatment of benign tumors, PD is a multiorgan resection involving loss of pancreatic and extrapancreatic tissue and functions. PD for benign neoplasm is associated with the risk of considerable early postoperative complications and an in-hospital mortality of up to 5%. Following the Whipple procedure a new onset of diabetes mellitus is observed in 14–20% and new exocrine insufficiency in 25–45%, leading to metabolic dysfunction and impairment of quality of life persisting after resection of benign tumors. Symptomatic neoplasms are indication for surgery. Patients with asymptomatic pancreatic tumors are treated according to the criteria of surveillance protocols. The goal of surgical treatment for asymptomatic patients is, according to the guideline criteria, interruption of the surveillance program before the development of an advanced stage cancer associated with the neoplasm. Tumor enucleation and duodenum-preserving pancreatic head resection, either total or partial, are parenchyma-sparing resections for benign neoplasms of the pancreatic head. The first choice for small tumors is enucleation; however, enucleation is associated with an increased risk of pancreatic fistula B + C following pancreatic main duct injury. Duodenum-preserving total or partial pancreatic head resection has the advantage of low postoperative surgery-related complications, a mortality of < 0.5% and maintenance of the endocrine and exocrine pancreatic functions. Parenchyma-sparing pancreatic head resections should replace classical Whipple procedures for neoplasms of the pancreatic head. [ABSTRACT FROM AUTHOR]

Pancreatic cancer is the most common medical condition that requires pancreatic resection. Over the last three decades, significant improvements have been made in the conditions and procedures related to pancreatic surgery, resulting in mortality rates lower than 5%. However, it is important to note that the morbidity in pancreatic surgery remains r latively high, with a percentage range of 30–60%. Pre-operative malnutrition is considered to be an independent risk factor for post-operative complications in pancreatic surgery, such as impaired wound healing, higher infection rates, prolonged hospital stay, hospital readmission, poor prognosis, and increased morbidity and mortality. Regarding the post-operative period, it is crucial to provide the best possible management of gastrointestinal dysfunction and to handle the consequences of alterations in food digestion and nutrient absorption for those undergoing pancreatic surgery. The European Society for Clinical Nutrition and Metabolism (ESPEN) suggests that early oral feeding should be the preferred way to initiate nourishing surgical patients as it is associated with lower rates of complications. However, there is ongoing debate about the optimal post-operative feeding approach. Several studies have shown that enteral nutrition is associated with a shorter time to recovery, superior clinical outcomes and biomarkers. On the other hand, recent data suggest that nutritional goals are better achieved with parenteral feeding, either exclusively or as a supplement. The current review highlights recommendations from existing evidence, including nutritional screening and assessment and pre/post-operative nutrition support fundamentals to improve patient outcomes. Key areas for improvement and opportunities to enhance guideline implementation are also highlighted. [ABSTRACT FROM AUTHOR]

Objective: Within a learning health system paradigm, this study sought to evaluate reasons for readmission to identify opportunities for improvement. Background: Post-pancreatectomy readmission rates have remained constant despite improved index hospitalization metrics. Methods: We performed a single-institution case-control study of consecutive patients with pancreatectomy (October 2016 to April 2022). Complications were prospectively graded in biweekly faculty and advanced practice provider meetings. We analyzed risk factors during index hospitalization and categorized indications for 90-day readmissions. Results: A total of 835 patients, median age 65 years and 51% (427/835) males, underwent 64% (534/835) pancreatoduodenectomies, 34% (280/ 835) distal pancreatectomies, and 3% (21/835) other resections. Twenty-four percent (204/835) of patients were readmitted. The primary indication for readmission was technical in 51% (105/204), infectious in 17% (35/204), and medical/metabolic in 31% (64/204) of patients. Procedures were required in 77% (81/105) and 60% (21/35) of technical and infectious readmissions, respectively, while 66% (42/64) of medical/metabolic readmissions were managed noninvasively. During the index hospitalization, benign pathology [odds ratio (OR): 1.8, P = 0.049], biochemical pancreatic leak (OR: 2.3, P = 0.001), bile/ gastric/chyle leak (OR: 6.4, P = 0.001), organ-space infection (OR: 3.4, P = 0.007), undrained fluid on imaging (OR: 2.4, P = 0.045), and increasing white blood cell count (OR: 1.7, P = 0.045) were independently associated with odds of readmission. Conclusions: Most readmissions following pancreatectomy were technical in origin. Patients with complications during the index hospitalization, increasing white blood cell count, or undrained fluid before discharge were at the highest risk for readmission. Predischarge risk stratification of readmission risk factors and augmentation of in-clinic resources may be strategies to reduce readmission rates. [ABSTRACT FROM AUTHOR]

Objective: To analyze the association of a surgeon’s experience with postoperative outcomes of pancreatoduodenectomies (PDs) when stratified by Fistula Risk Score (FRS). Background: Centralization is now well-established for pancreatic surgery. Nevertheless, the benefits of individual surgeon’s experience in high-volume settings remain undefined. Methods: Pancreatoduodenectomies performed by 82 surgeons across 18 international specialty institutions (median: 140 PD/year) were analyzed. Surgeon cumulative PD volume was linked with postoperative outcomes through multivariable models, adjusted for patient/operative characteristics and the FRS. Then, surgeon experience was also stratified by the 10, previously defined, most clinically impactful scenarios for clinically relevant pancreatic fistula (CR-POPF) development. Results: Of 8189 PDs, 18.7% suffered severe complications (Accordion≥3), 4.8% were reoperated upon and 2.2% expired. Although the most experienced surgeons (top-quartile; >525 career PDs) more often operated on riskier cases, their experience was significantly associated with declines in CR-POPF (P<0.001), severe complications (P=0.008), reoperations (P<0.001), and length of stay (LOS) (P<0.001)—accentuated even more in the most impactful FRS scenarios (2830 patients). Risk-adjusted models indicate male sex, increasing age, ASA class, and FRS, but not surgeon experience, as being associated with severe complications, failure-to-rescue, and mortality. Instead, upper-echelon experience demonstrates significant reductions in CR-POPF (OR 0.66), reoperations (OR 0.64), and LOS (OR 0.65) in moderate-to-high fistula risk circumstances (FRS≥3, 68% of cases). Conclusions: At specialty institutions, major morbidity, mortality, and failure-to-rescue are primarily associated with baseline patient characteristics, while cumulative surgical experience impacts pancreatic fistula occurrence and its attendant effects for most higher-risk pancreatoduodenectomies. These data also suggest an extended proficiency curve exists for this operation. [ABSTRACT FROM AUTHOR]

Objective: Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center. Background: The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable. Materials and Methods: Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a “zero-crossing” technique was used, which produced “first and second derivatives” to identify volume thresholds. Results: Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df (edf ) 5.154 (P< 0.001) and 8.254 (P< 0.001), respectively. The threshold value for mortality was ~45 PDs/year (model edf 9.219 (P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost (edf=2, P=0.989) and length of stay (edf=2.04, P=0.099). Conclusions: There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year. [ABSTRACT FROM AUTHOR]

Postoperative pancreatic fistula (POPF) is a major cause of morbidity and mortality after pancreatoduodenectomy (PD), and previous research has focused on patient-related risk factors and comparisons between anastomotic techniques. However, it is recognized that surgeon experience is an important factor in POPF outcomes, and that there is a significant learning curve for the pancreatic anastomosis. The aim of this study was to review the current literature on training models for the pancreatic anastomosis, and to explore areas for future research. It is concluded that research is needed to understand the mechanical properties of the human pancreas in an effort to develop a synthetic model that closely mimics its mechanical properties. Virtual reality (VR) is an attractive alternative to synthetic models for surgical training, and further work is needed to develop a VR pancreatic anastomosis training module that provides both high fidelity and haptic feedback. [ABSTRACT FROM AUTHOR]

Purpose of review: Pancreatic resection stands as one of the most challenging abdominal surgeries, primarily indicated for pancreatic malignancies such as pancreatic ductal adenocarcinoma (PDAC), pre-malignant conditions like intraductal papillary mucinous neoplasm (IPMN), and benign pathologies that manifest with significant symptoms, including intractable pain, often concomitant with endocrine or exocrine dysfunction. The inherent complexity and morbidity associated with pancreatic resection, exacerbated by the high risk of pancreatic anastomosis complications, including pancreatic leaks of amylase-rich fluid, is further amplified by the pancreas's retroperitoneal location near vital anatomical structures. This underscores the imperative need for a thorough assessment of emerging surgical approaches, with particular attention to the application of robotic technology. This review appraises the impact of robotic-assisted surgery on the operative and oncological outcomes of patients afflicted with benign and malignant, pancreatic and peri-pancreatic, diseases. Recent findings: Robotic surgery has exhibited a correlation with enhanced post-operative outcomes such as reduced morbidity and mortality following pancreatic resections. Furthermore, it has demonstrated a positive association with improved oncological resection and outcomes in patients diagnosed with pancreatic and peri-pancreatic cancer. Summary: Minimally invasive surgery has substantially refined the landscape of pancreatic resections, offering diminished post-operative pain and reduced hospital stay. Robotic surgery, distinguished by its superior visualization and meticulous tissue handling capabilities, enables precise dissection and seamless anastomosis in the complex realm of pancreatic surgery. Consequently, this has translated into ameliorated morbidity and mortality in this patient cohort, emphasizing the critical role of surgeon proficiency and case volume. Minimally invasive resection in the context of malignancy has demonstrated favorable oncological outcomes. This is potentially attributed to improved oncological resection (increased negative margins and lymph node yield) expedited post-operative recovery, facilitating prompt initiation of adjuvant therapy and attenuating surgical stress-induced tumorigenesis. Nonetheless, future randomized controlled trials are indispensable to comprehensively elucidate the impact of robotic resection on the host immune response and long-term outcomes following pancreatic resections, encompassing both benign and malignant etiologies. Such investigations hold the promise of advancing our understanding and optimizing the role of robotic surgery in the context of pancreatic diseases. [ABSTRACT FROM AUTHOR]

Median arcuate ligament syndrome (MALS) is an uncommon condition characterized by the compression of the celiac trunk by the median arcuate ligament. Due to the anatomical proximity to the foregut, MALS has significant implications in hepato-pancreato-biliary (HPB) surgery. It can pose complications in pancreatoduodenectomy and orthotopic liver transplantation, where the collateral arterial supply from the superior mesenteric artery is often disrupted. The estimated prevalence of MALS in HPB surgery is approximately 10%. Overall, there is consensus for a cautious approach to MALS when embarking on complex foregut surgery, with a low threshold for intraoperative median arcuate ligament release or hepatic artery reconstruction. The role of endovascular intervention in the management of MALS prior to HPB surgery continues to evolve, but more evidence is required to establish its efficacy. Recognizing the existing literature gap concerning optimal management in this population, we describe our tertiary center experience as a clinical algorithm to facilitate decision-making. Research question: What is the significance and management of median arcuate ligament syndrome in patients undergoing hepato-pancreato-biliary surgery? [ABSTRACT FROM AUTHOR]

Introduction: Minimally invasive Pancreatoduodenectomy (MIPD), or the Whipple procedure, is increasingly utilized. No study has compared laparoscopic (LPD) and robotic (RPD) approaches, and the impact of the learning curve on oncologic, technical, and post-operative outcomes remains relatively understudied. Methods: The National Cancer Database was queried for patients undergoing LPD or RPD from 2010 to 2020 with a diagnosis of pancreatic cancer. Outcomes were compared between approaches using propensity-score matching (PSM); the impact of annual center-level volume of MIPD was also assessed by dividing volume into quartiles. Results: A total of 3,342 patients were included. Most (n = 2,716, 81.3%) underwent LPD versus RPD (n = 626, 18.7%). There was a high rate (20.2%, n = 719) of positive margins. Mean length-of-stay (LOS) was 10.4 ± 8.9 days. Thirty-day mortality was 2.8% (n = 92) and ninety-day mortality was 5.7% (n = 189). PSM matched 625 pairs of patients receiving LPD or RPD. After PSM, there was no differences between groups based on age, sex, race, CCI, T-stage, neoadjuvant chemo/radiotherapy, or type of PD. After PSM, there was a higher rate of conversion to open (HR = 0.68, 95%CI = 0.50–0.92)., but there was no difference in LOS (HR = 1.00, 95%CI = 0.92–1.11), 30-day readmission (HR = 1.08, 95% CI = 0.68–1.71), 30-day (HR = 0.78, 95% CI = 0.39–1.56) or 90-day mortality (HR = 0.70, 95% CI = 0.42–1.16), ability to receive adjuvant therapy (HR = 1.15, 95% CI = 0.92–1.44), nodal harvest (HR = 1.01, 95%CI = 0.94–1.09) or positive margins (HR = 1.19, 95% CI = 0.89–1.59). Centers in lower quartiles of annual volume of MIPD demonstrated reduced nodal harvest (p = 0.005) and a higher rate of conversion to open (p = 0.038). Higher-volume centers had a shorter LOS (p = 0.012), higher rate of initiation of adjuvant therapy (p = 0.042), and, most strikingly, a reduction in 90-day mortality (p = 0.033). Conclusion: LPD and RPD have similar surgical and oncologic outcomes, with a lower rate of conversion to open in the robotic cohort. The robotic technique does not appear to eliminate the "learning curve", with higher volume centers demonstrating improved outcomes, especially seen at minimum annual volume of 5 cases. [ABSTRACT FROM AUTHOR]

Introduction: Pancreatic cancer recurrence following surgery is a significant challenge, and personalized surgical care is crucial. Topographical variations in pancreatic duct anatomy are frequent but often underestimated. This study aimed to investigate the potential importance of these variations in outcomes and patient survival after Whipple's procedures. Methods: Data were collected from 105 patients with confirmed pancreatic head neoplasms who underwent surgery between 2008 and 2020. Radiological measurements of pancreatic duct location were performed, and statistical analysis was carried out using IBM SPSS. Results: Inferior pancreatic duct topography was associated with an increased rate of metastatic spread and tumour recurrence. Additionally, inferior duct topography was associated with reduced overall and recurrence‐free survival. Posterior pancreatic duct topography was associated with decreased incidence of perineural sheet infiltration and improved overall survival. Discussion: These findings suggest that topographical diversity of pancreatic duct location can impact outcomes in Whipple's procedures. Intraoperative review of pancreatic duct location could help surgeons define areas of risk or safety and deliver a personalized surgical approach for patients with beneficial or deleterious anatomical profiles. This study provides valuable information to improve surgical management by identifying high‐risk patients and delivering a personalized surgical approach with prognosis stratification. [ABSTRACT FROM AUTHOR]

Objective: To describe long-term quality of life (QOL) and gastrointestinal (GI) symptoms in patients who underwent pancreatoduodenectomy for pancreatic cancer in the modern era. Background: As advances in pancreatic cancer management improve outcomes, it is essential to assess long-term patient-reported outcomes after surgery. Methods: Patients who underwent curative intent pancreatoduodenectomy for pancreatic cancer between January 2011 and June 2019 from a single center were identified. Patients alive ≥3 years after surgery were considered long-term survivors (LTS). LTS who were alive in June 2022 received a 55-question survey to assess their QOL (EORTC-QLQ-C30) and GI symptoms (EORTC-PAN26 and Problem Areas in Diabetes Questionnaire). Responses were compared against population norms. Clinicodemographic characteristics in LTS versus non-LTS and survey completion were compared. Results: Six hundred seventy-two patients underwent pancreatoduodenectomy for pancreatic cancer; 340 were LTS. One hundred thirty-seven patients of the 238 eligible to complete the survey responded (response rate: 58%). Compared to the US general population, LTS reported significantly higher QOL (75 vs 64; P<0.001), less nausea/vomiting, pain, dyspnea, insomnia, appetite loss, and constipation, but more diarrhea (all P<0.001). Most patients (n=136/137, 99%) reported experiencing postoperative GI symptoms related to pancreatic insufficiency (n=71/135, 53%), reflux (n=61/135, 45%), and delayed gastric emptying (n=31/136, 23%). Most patients (n=113/136, 83%) reported that digestive symptoms overall had little to no impact on QOL, and 91% (n=124/136) would undergo surgery again. Conclusions: Despite known long-term complications following pancreatoduodenectomy, cancer survivors appear to have excellent QOL. Specific long-term gastrointestinal symptoms data should be utilized for preoperative education and follow-up planning. [ABSTRACT FROM AUTHOR]

Summary: This literature review reflects the present evidence on minimally invasive pancreatic surgery, differentiating between distal pancreatic resection and pancreatoduodenectomy for pancreatic cancer. The review analyzed studies comparing minimally invasive and open pancreatic surgery in PubMed, the Cochrane Library, and the WHO Trial Register according to the following MeSH search strategy: MeSH items: pancreatic surgery, minimally invasive surgery, robotic surgery, laparoscopic surgery, pancreatoduodenectomy, and distal pancreatic resection. In systematic reviews and meta-analysis, minimally invasive distal pancreatectomy (MI-DP) has been shown to result in shorter hospital stays, less blood loss, and better quality of life than open distal resection (ODP) with similar morbidity and mortality. Meta-analyses have suggested similar oncological outcomes between the two approaches. Minimally invasive pancreatoduodenectomy (MI-PD) has been shown to offer advantages over open surgery, including shorter length of stay and less blood loss, by expert surgeons in several studies. However, these studies also reported longer operative times. As the procedure is technically demanding, only highly experienced pancreatic surgeons have performed MI-PD in most studies, so far limiting widespread recommendations. In addition, selection of cases for minimally invasive operations might currently influence the results. Registry studies from dedicated groups such as the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS) and randomized controlled trials currently recruiting (DIPLOMA‑1 and 2, DISPACT-2) will bring more reliable data in the coming years. In conclusion, both MI-DP and MI-PD have shown some advantages over open surgery in terms of shorter hospital stays and reduced blood loss, but their effectiveness in terms of oncological outcomes is uncertain due to limited evidence. The study highlights the need for further randomized controlled trials with larger sample sizes and registry studies to further evaluate the safety, efficacy, and oncological outcomes of minimally invasive pancreatic resections. [ABSTRACT FROM AUTHOR]

Background: This meta‐analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared to conventional care on postoperative outcomes in patients aged 70 years or older undergoing pancreatoduodenectomy (PD). Methods: Five databases were systematically searched. Comparative studies with available individual patient data (IPD) were included. The main outcomes were postoperative morbidity, length of stay, readmission and postoperative functional recovery elements. To assess an age‐dependent effect, the group was divided in septuagenarians (70–79 years) and older patients (≥80 years). Results: IPD were obtained from 15 of 31 eligible studies comprising 1109 patients. The overall complication and major complication rates were comparable in both groups (OR 0.92 [95% CI: 0.65–1.29], p =.596 and OR 1.22 [95% CI: 0.61–2.46], p =.508). Length of hospital stay tended to be shorter in the ERAS group compared to the conventional care group (−0.14 days [95% CI: −0.29 to 0.01], p =.071) while readmission rates were comparable and the total length of stay including days in hospital after readmission tended to be shorter in the ERAS group (−0.28 days [95% CI: −0.62 to 0.05], p =.069). In the subgroups, the length of stay was shorter in octogenarians treated with ERAS (−0.36 days [95% CI: −0.71 to −0.004], p =.048). The readmission rate increased slightly but not significantly while the total length of stay was not longer in the ERAS group. Conclusion: ERAS in the elderly is safe and its benefits are preserved in the care of even in patients older than 80 years. Standardized care protocol should be encouraged in all pancreatic centers. [ABSTRACT FROM AUTHOR]