Background: When endoscopic resection of ampullary neuroendocrine tumors (NETs) is not feasible due to tumour size or location, transduodenal ampullectomy can offer a parenchymal-sparing alternative to a formal pancreaticoduodenectomy (Whipple procedure) [1,2]. We present a robotic-assisted transduodenal ampullectomy (RATA) in a 71-year-old male with an incidental 14 mm ampullary NET found during routine screening. Preoperative 68Ga-DOTATATE PET-CT demonstrated intense somatostatin-receptor avidity (SUVmax 66.8) and absent FDG uptake. The MDT recommended surgical excision due to size and Ki-67 4%. Methods: Following right colonic flexure mobilisation and a Kocher maneuver, the cystic duct was isolated and cannulated with a 4 Fr catheter to guide biliary identification. After a longitudinal duodenotomy, the ampullary lesion was visualized. Submucosal saline-adrenaline was injected in the submucosal plane. Diathermy scissors were used to perform a circumferential mucosal and muscularis dissection. Biliary and pancreatic ducts were sharply divided and reconstructed using interrupted 5/0 polydioxanone sutures between the pancreatobiliary ducts and the duodenal mucosa after positioning a 6 Fr catheter in the pancreatic duct. The duodenotomy was closed in two layers using a 4/ 0 absorbable barbed suture, and a methylene blue leak test through the nasogastric tube confirmed duodenal integrity. Results: The procedure was completed successfully with no intraoperative complications. A postoperative contrast-enhanced CT on day 5 demonstrated no collections and no oral contrast extravasation. Oral feeding was gradually reintroduced, the abdominal drain was removed, and the patient was discharged on day 7. Following a brief readmission on day 13 for a pulmonary microembolism successfully treated with medical therapy, the patient recovered fully and remains disease-free 7 months after surgery. Conclusion: RATA can represent a safe, feasible, and pancreas-preserving alternative to formal pancreaticoduodenectomy for well-differentiated ampullary NETs in selected patients. The robotic platform enhances three-dimensional visualization and wrist articulation, optimizing the delicate micro-reconstruction of the pancreaticobiliary junction.
Background: It is unknown whether the preoperative anesthesiological risk assessment interacts with patient age in colorectal cancer (CRC) to increase the risk of early postoperative mortality beyond that explained by the independent effects of age and anesthesiological risk assessment. Methods: We conducted a nationwide cohort study (2014-2023) of all Danish non-metastatic CRC patients (UICC pathological TNM I-III) aged 70 or more years at time of surgery (n = 15,673). To analyse perioperative risk, we used the American Society of Anesthesiologists (ASA) Physical Status Classification system score. The study cohort was stratified by age at CRC surgery (70-79, 80+) and ASA classification (I, II, III). We estimated mortality rates per 1000 person-days, and calculated interaction contrasts as a measure of the excess mortality rate not explained by the independent effects of age or ASA classification. Results: 90-day overall survival was lower in patients aged >= 80 years compared with those aged 70-79 years (94.0% vs. 97.9%). Increasing ASA classification was associated with progressively lower survival, with 90-day survival of 98.9% for ASA I, 97.9% for ASA II, and 93.1% for ASA III. Interaction analyses demonstrated that the combined effect of age and ASA classification exceeded their independent effects, with interaction contributing 21% of the mortality rate in ASA II patients aged >= 80 years and 36% in ASA III patients aged >= 80 years. Discussion: Old CRC patients assessed as ASA III have a high risk of perioperative mortality and may benefit from risk factor reductions or high intensity postoperative monitoring to reduce mortality.
Introduction: Laparoscopic adrenalectomy is the standard minimally invasive approach for adrenal tumors, and robotic-assisted surgery has increasingly been adopted as an alternative. Comparative studies have not consistently demonstrated superiority of either technique, and most are limited by confounding by indication, as robotic programs are introduced after laparoscopic practice is already established. We compared perioperative outcomes between robotic and laparoscopic adrenalectomy at a single center using propensity-score matching to reduce this confounding. Methods: This retrospective, single-center study included all consecutive patients undergoing laparoscopic or robotic transabdominal adrenalectomy between May 2021 and March 2026 (n = 96; 58 laparoscopic, 38 robotic), after excluding 19 patients with a non-minimally invasive approach from the outset. Patients were matched 1:1 by nearest-neighbor propensity-score matching (caliper 0.2 standard deviations of the logit propensity score) on age, sex, body mass index, ASA class, tumor size, and functional status. Calendar year of surgery was not included in the matching model, owing to quasi-complete separation, but was assessed for balance and addressed in a sensitivity analysis. Continuous outcomes were compared using the paired Wilcoxon signed-rank test and binary outcomes using McNemar's test. Results: Matching yielded 35 pairs (70 patients), well balanced on all matched covariates (standardized mean difference <= 0.12). Operative time did not differ significantly between groups (median 105 versus 95 min, p = 0.174). Length of hospital stay was shorter with the robotic approach in the unadjusted analysis (p = 0.026), but this difference was no longer significant after adjusting for calendar year of surgery (p = 0.391). Rates of vasopressor use, transfusion, intraoperative and postoperative complications, conversion to open surgery, and readmission were low (0-3 events per group) and did not differ significantly between groups. One death occurred in the matched cohort (robotic group), related to progression of metastatic disease rather than surgery. Discussion: Our findings are broadly consistent with recent comparative and propensity-matched studies showing similar perioperative safety profiles for robotic and laparoscopic adrenalectomy. The attenuation of the length-of-stay difference after adjusting for calendar year illustrates the risk of attributing temporal trends in perioperative care to the surgical approach itself, a consideration relevant to any single-center comparison spanning the introduction of a new surgical platform. Conclusion: In this propensity-score matched cohort, robotic and laparoscopic adrenalectomy showed comparable perioperative outcomes, without clear superiority of either approach. Larger, multicenter studies are needed to confirm these findings, particularly for infrequent outcomes.
Background: Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare and heterogeneous primary liver malignancy with poor outcomes after resection. This study aimed to develop and preliminarily validate postoperative prognostic models incorporating clinical, pathological, and inflammatory variables. Patients and methods: We retrospectively analyzed 182 patients with pathologically confirmed cHCC-CCA who underwent curative-intent hepatectomy at two centers, including 145 patients in the training cohort and 37 in the external validation cohort. LASSO regression and multivariable Cox regression were used to identify predictors of overall survival (OS) and disease-free survival (DFS). Results: Independent predictors of OS were HBV status, tumor differentiation, tumor diameter, HCC AJCC stage, and neutrophil-to-lymphocyte ratio. Independent predictors of DFS were HBV status, MVI, tumor diameter, AFP and monocyte-to-lymphocyte ratio. These factors collectively span the four VITAL dimensions. The VITAL nomograms outperformed conventional HCC and ICC staging systems in both cohorts and effectively stratified patients by risk. Conclusions: The VITAL nomogram integrates viral, inflammatory, tumor biological, and anatomical dimensions into a single instrument, providing superior postoperative risk stratification compared with conventional staging in cHCC-CCA. Further multicenter validation is warranted.
Background: Duodenal laparoscopic and endoscopic cooperative surgery (D-LECS) is an alternative to endoscopic submucosal dissection (ESD) for duodenal tumors, but technical instability and adverse events remain concerns. We aimed to describe the short-term outcomes of refined D-LECS and temporal changes in horizontal margin status and operative time. Methods: This retrospective single-center study included 40 patients who underwent D-LECS between August 2021 and February 2026. Refinements included complete Kocher mobilization to straighten the duodenum and stabilize ESD, use of a Clutch Cutter under the water pressure method for safe dissection and hemostasis, duodenal re-fixation to restore physiological orientation, full-thickness horizontal mattress suturing for secure defect closure, and selective use of the reopenable clip-over-the-line method for defects at the pancreatic attachment. The primary endpoint was delayed perforation; secondary endpoints included postoperative outcomes, pathological margin status, R0 resection, and operative time. Results: En bloc resection was achieved in all cases. Nine patients (22.5%) experienced Clavien-Dindo Grade II complications, and two patients (5.0%) experienced Grade III complications, including one delayed perforation and one wound infection requiring drainage. No patient required reoperation, and DGE occurred in one patient (2.5%). Median postoperative hospital stay was 8 days. HM1/HMX was observed in 5 lesions, while VMX was observed in 1 lesion and no lesion was VM1. The pathological R0 resection rate was 87.5% (35/40). HM1/HMX was observed in 4 of 12 patients (33.3%) in the early phase and 1 of 28 patients (3.6%) in the late phase. Mean operation time decreased from 323 min in the early phase to 270 min in the late phase (p = 0.048). Conclusions: Refined D-LECS was associated with acceptable short-term outcomes in this single-center retrospective series. HM1/HMX was less frequent and operation time was shorter in the later phase, although these temporal changes cannot be attributed to individual technical refinements.
