Objective: To assess the feasibility of and clinical outcomes after a pan-European training program for robotic pancreatoduodenectomy (RPD).Summary Background Data: The implementation of RPD into clinical practice comes with considerable challenges, leading to concerns about patient safety, oncological outcomes, and costs. To address this, a structured training program was implemented in which 2 surgeons at each of the 20 sites were trained and maintained as a consistent operative team. Study Design: A structured training program for RPD was implemented, and outcomes were prospectively collected in 20 European high-volume centers, all without previous RPD experience, from 12 countries. The program included a video library, biotissue simulation (pancreaticojejunostomy and hepaticojejunostomy), off-site RPD case observations, and on-site proctoring. Surgeons' simulation anastomoses were assessed using Objective Structured Assessment of Technical Skills (OSATS) and technical errors. The primary endpoint was intra- and postoperative patient outcome. A key secondary analysis assessed safety using OSATS scores and error counts during the biotissue training.. Results: Overall, 486 RPD procedures were performed. Median intraoperative blood loss was 200 mL (IQR: 100-400), operative time was 475 minutes (IQR: 414-553.3), and the conversion rate was 18.3% (n=89). The rate of Clavien-Dindo grade >= III complications was 31.4% (n=153), POPF was 21.2% (n=103), delayed gastric emptying was 15% (n=73), postpancreatectomy hemorrhage was 8.6% (n=42), and in-hospital/30-day mortality was 2.7% (n=13). Median length of stay was 12 days (IQR: 8-20). During simulation training, OSATS scores significantly improved (0.350 points/attempt (rho), P<0.001) while the duration of reconstruction decreased (P<0.001). There was a significant decrease of the total number of errors made during consecutive attempts in the biotissue training (0.175 errors decrease per attempt, P=0.006]). Conclusions: We report on the first successfully completed international training program for RPD. Simulation established a standardized technical competency, although a learning-curve effect (POPF) remained detectable per center. These data highlight that safe adoption of complex procedures requires structured, team-based, proctored training beyond simulation alone.
BACKGROUND: Approximately 30% of patients develop liver-confined recurrences after local treatment for colorectal liver metastases (CRLM), which may be reduced by adjuvant therapy. Hepatic arterial infusion pump (HAIP) chemotherapy delivers high-dose liver-directed chemotherapy. OBJECTIVE: To investigate adjuvant HAIP chemotherapy without systemic therapy in patients with resectable liver-confined recurrence after prior local treatment of CRLM. METHODS: This multicenter, single-arm phase II trial enrolled patients with resectable recurrent CRLM across 3 centers in the Netherlands. Patients with prior or present extrahepatic disease were excluded. Adjuvant HAIP with floxuridine was administered up to 6 cycles. The primary endpoint was hepatic disease-free survival (hDFS) estimated using the Kaplan-Meier method, with a prespecified efficacy boundary of 36 months. RESULTS: Forty-five patients underwent local treatment followed by adjuvant HAIP chemotherapy without systemic therapy. Twenty-eight patients(62%) were treated for a first recurrent CRLM, and 17 patients for a second or higher. Twenty-five patients (56%) had ≥3 CRLM. All patients started HAIP chemotherapy, with a median of 6 cycles (interquartile range: 4 to 6). After a median follow-up of 38.7 months (95% CI: 33.0-42.3), the median hDFS was 16.5 months (95% CI: 9.1-25.8). The median progression-free survival was 14.0 months (95% CI: 7.7-23.0), and the 3-year overall survival was 71% (95% CI: 58%-87%). Initial recurrence included the liver in 23 patients (51%). HAIP implantation-related complications (Clavien-Dindo grade ≥3) occurred in 4 patients (9%), and HAIP chemotherapy-related complications (Common Terminology Criteria for Adverse Events grade ≥3) occurred in 6 patients (13%). Biliary sclerosis occurred in 4 patients; 3 required stent placement. CONCLUSION: Adjuvant HAIP chemotherapy without systemic therapy did not achieve the hypothesized hDFS in patients undergoing repeat local treatment for recurrent CRLM.
Objective: To evaluate the independent association between sociobehavioral comorbidities (SBCs) and complications after colectomies in a national Veteran cohort. Background: SBCs are determinants of health outcomes, and Veterans represent a high-vulnerability population. However, the relationship of SBCs with postoperative complications remains understudied, and current surgical risk models underestimate risk among patients with significant SBC burden. Methods: We conducted an observational study of Veterans undergoing elective colectomy included in the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Structured data from the Veteran Health Administration Corporate Data Warehouse were used to identify 6 SBC phenotypes (mental health disorder, suicide risk, substance use, social isolation, housing instability, and food insecurity) across 3 preoperative ascertainment windows: ≤90 days, ≤365 days, and lifetime. The outcome was any 30-day VASQIP-defined postoperative complication. Multilevel logistic regression estimated associations between SBCs and complications. Results: Among 38,188 Veterans undergoing colectomy between 2009 and 2025, the median age was 66 years; 5% were female; 30% were non-white; and 48% had cancer. Mental health disorder, social isolation, or substance use were each associated with an 8%–40% increase in the odds of a complication across all ascertainment windows. Within the most proximal window, risk of complication increased as SBC burden increased: 16% increased odds with 1 SBC (aOR 1.16, 95% CI: 1.09–1.23) and 80% increased odds with 4–6 SBCs (aOR 1.80, 95% CI: 1.32–2.36). Conclusions: In a national Veteran cohort, SBCs were associated with postoperative colectomy complications. The strongest associations were observed with SBCs ascertained within the 90-day window, and the odds increased in a dose-response relationship with increasing SBC burden.
Objective: To assess the prognostic utility of the Metro-Pancreas framework in resectable pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant chemotherapy (NAT) and resection. Summary Background Data: Upfront surgery and NAT are options in anatomically resectable PDAC. Metro-Pancreas combines tumor size and CA 19-9 to stratify prognosis after upfront resection, but its applicability after NAT is unknown. Methods: We analyzed 623 patients with nonmetastatic, anatomically resectable PDAC who underwent NAT followed by resection from 5 institutions (2016–2024). Metro-Pancreas classification ( IN/OUT ) was determined by tumor size and CA19-9 levels. Treatment response followed NCCN 2026 definition based on radiologic and biochemical changes. Postoperative disease-free survival (DFS) and overall survival (OS) were evaluated. Results: At diagnosis, 263 patients (42.2%) were Metro-Pancreas OUT and had shorter postoperative DFS (13.3 vs. 16.7 mo; P =0.003) and OS (29.5 vs. 34.8 mo; P =0.006) than Metro-Pancreas IN patients. After NAT, 71.9% of OUT patients were reclassified as IN , while 5.0% of initially IN patients became OUT . Among baseline OUT patients, 35.7% had significant response, 46.0% had minimal response, and 18.3% had progression. Prognostic separation was greater at Metro-Pancreas restaging (DFS: 7.7 vs. 17.3 mo; OS: 15.8 vs. 36.7 mo; both P =0.001). Patients reclassified from OUT to IN had postoperative DFS and OS comparable to those initially IN ( P =0.806 and P =0.631, respectively). Conclusions: Among patients undergoing resection after NAT, Metro-Pancreas stratified prognosis at diagnosis and more effectively at restaging. Reclassification from OUT to IN was associated with favorable postoperative survival, supporting dynamic prognostic reassessment in the neoadjuvant setting.
