Background Postoperative pancreatic fistulas (POPF) are a major complication following distal pancreatectomy, with no consensus on the optimal stump management technique. This study aimed to evaluate a novel non-closure technique using electrothermal and saline-coupled bipolar tissue sealers. We conducted a retrospective review to assess its impact on POPF incidence. Methods In this single-institution, retrospective consecutive case series, we evaluated patients who underwent distal pancreatectomy using LigasureTM and AquamantysTM for pancreatic transection from 2018 to 2025. Patient demographics, operative details, and postoperative outcomes were analyzed, with emphasis on clinically relevant POPF. As a secondary analysis, the incidence of POPF in this sample was compared to that in the National Surgical Quality Improvement Program database (NSQIP). Results We identified 30 patients who underwent distal pancreatectomy utilizing this technique. No clinically relevant POPFs (either Grade B or C) were observed. No patients required reoperation or had POPF-related readmission. The incidence of POPF in this sample was lower than the 16.4% incidence within the NSQIP pancreatectomy database over this period of time (p = 0.02). Conclusion Our findings suggest that combining LigasureTM and AquamantysTM for non-closure of the pancreatic stump is a safe and feasible technique, with no clinically relevant POPF observed in this cohort.

Pancreas divisum, a congenital failure of fusion between the dorsal and ventral pancreatic buds, occurs in ~10% of the population. The prevalence of intraductal papillary mucinous neoplasm (IPMN) of the ventral duct in pancreas divisum is not well established. Malignant transformation is exceptionally rare, with this case being the first documented in the USA. A 74-year-old man presented with new-onset obstructive jaundice. A computed tomography of the abdomen and pelvis showed pancreas divisum with a 4-cm cystic mass causing a 1.8 cm ventral pancreatic duct dilatation, concerning for an IPMN. Cyst fluid analysis demonstrated elevated fluid amylase and carcinoembryonic antigen. Due to high-risk stigmata, the patient underwent a Whipple procedure and was found to have a 3.5-cm pancreatic cancer arising from an IPMN of the ventral duct. Given the risk of progression, patients with pancreas divisum who develop ventral duct IPMN require careful surveillance and timely escalation of care when appropriate.

Background Radical resection is recommended for clinical T2N0 rectal cancer, yet some patients receive local excision or neoadjuvant therapy, practices traditionally excluded from national guidelines for this stage. We aimed to assess treatment patterns and the impact of surgical approach and neoadjuvant therapy on overall survival. Methods This was a retrospective cohort study utilizing the American College of Surgeons National Cancer Database. Patients diagnosed with clinical T2N0 rectal adenocarcinoma who underwent local excision or radical resection were included. The primary outcome was overall survival. Results Of 11,513 patients, 1,853 (16.1%) underwent local excision and were older, more comorbid, and more likely to be female (all p < 0.001). Five-year survival was lower for local excision (65.4%) versus radical resection (77.2%), p < 0.001). This persisted across neoadjuvant therapy subgroups. Local excision was associated with worse survival (HR = 1.15, 95% CI: 1.06-1.25, p < 0.001). Neoadjuvant chemoradiation conferred increased hazard of death compared to no neoadjuvant therapy (HR = 1.20, 95% CI: 1.11-1.30, p < 0.001). Highest risk was observed in patients receiving both local excision and neoadjuvant chemoradiation (HR = 1.36, 95% CI: 1.13-1.63, p < 0.001). Conclusions Since 2006, local excision and neoadjuvant therapy have been used in a stable minority of patients with T2N0 disease. Recent guidelines have incorporated these treatment options. Data suggest worse overall survival associated with this minority group, highlighting the need for prospective studies to define optimal treatment strategies.

Background:One percent of pancreatic adenocarcinoma (PDAC) patients are diagnosed with new onset diabetes (NOD) over the age of 50 years within 3 years. Therefore, NOD is a major factor for early diagnosis of PDAC. Research has focused on understanding the differences between NOD and type 2 diabetes, particularly in relation to PDAC. However, conflicting data exists regarding their impact on survival outcomes in PDAC patients. We performed this multi-center study to assess the prevalence and influence of NOD on clinical outcomes in patients with PDAC within a community-based hospital system. Methods:We conducted a retrospective cohort study of 138 patients with biopsy-proven PDAC with localized/borderline disease (n=70), and metastatic disease (n=68) at three institutions from 2014 to 2021. NOD group consisted of pts diagnosed with diabetes [hemoglobin A1c (HbA1c) >6.5%] or pre-diabetes (HbA1c 5.7-6.4%) within the 3 years prior to PDAC diagnosis. Primary aim of the study was to determine the impact of NOD on clinical outcomes. Results:A total of 138 patients were included in the study, from which 30 met the criteria for NOD. No significant differences were noted in the demographic and clinical characteristics comparing patients based on NOD history. Comparing survival outcomes, NOD group was associated with worse overall survival (OS) in both the metastatic cohort [n=68, progression-free survival (PFS) 4.6 vs. 7.1 months, P=0.07; OS 7.1 vs. 13.2 months, P=0.01) and the resected cohort (n=40, PFS 8.4 vs. 19.3 months, P=0.04; OS 24.5 vs. 42.3 months, P=0.04). In multivariate analysis, the impact of NOD remained significant for OS and PFS in the resected cohort. Identifying common features amongst the NOD group, we found the entire cohort had a significant reduction in individual body mass index (BMI) 1 year prior to the NOD diagnosis (P=0.006). Conclusions:NOD is associated with worse survival outcomes in patients with metastatic and resected PDAC. Reduction of BMI prior to diagnosis of NOD, warrants further investigation to be incorporated into the PDAC screening paradigm.

Background: A subset of patients in ACS-NCDB with stage-1 colon cancer received adjuvant chemotherapy (AC), in contrast to national guidelines. This study aimed to define this population and evaluate associations between AC and survival. Methods: Patients with T1-2N0 colon cancer from 2004 to 2016 were separated into AC and non-AC groups. Adverse pathological features (APF) included T2, poor differentiation, lymphovascular invasion, positive margin, and inadequate lymph nodes (<12). Cox proportional hazard models were used to estimate prognostic factors for overall survival (OS). Results: A total of 1745 of 139,857 patients (1.2 %) received AC. Receiving AC was associated with male sex (p = 0.02), uninsured (p < 0.01), low income (p = 0.02), or having >= 2 APFs (p < 0.001). In the total cohort, AC was associated with increased mortality (HR 1.14 [1.04-1.24] P < 0.01). On subset analysis, AC was associated with improved OS for patients with >= 2 APFs (log-rank P=<0.001), and decreased mortality when adjusted for covariates (HR 0.81 [0.69-0.95] P=<0.01). The most significant predictor of mortality was old age (HR 3.78 [3.67, 3.89] p <= 0.01), followed by higher Charlson Comorbidity Index (HR 1.73 [1.69, 1.76] (p <= 0.01), and higher APF score (HR 1.46 [1.42, 15.2] p <= 0.01). Conclusion: AC was associated with decreased survival in the total cohort of stage 1 colon cancer patients, but was associated with improved survival for patients with multiple APFs.

Background: The simplified frailty index (sFI) is a commonly used instrument to estimate postoperative risk, but its correlation with phenotypic frailty has been questioned. This study evaluates the relationship between sFI and phenotypic frailty, as measured by the Sinai Abbreviated Geriatric Evaluation (SAGE).Methods: Charts were retrospectively reviewed from patients >= 75 years old who underwent surgery between 2012-2022. The sFI score was calculated by adding 1 point for hypertension, COPD, congestive heart failure, functional dependence, and diabetes (score 0-5). SAGE was calculated by adding 1 point for normal gait speed, normal Mini-Cog (c), and independent activities of daily living (ADL) (0-3). Spearman rank correlation was used to test the relationship between sFI and SAGE. SAGE components were used as binary-dependent outcomes in covariate-adjusted logistic regression modeling to evaluate associations with sFI scores while adjusting for potential confounders.Results: 334 patients were assessed, with a mean age of 84.0. SAGE and sFI scores were significantly associated, with a modest inverse relationship (r=-0.24, p<0.0001). Each 1-point increase in sFI score was associated with increased odds of ADL deficit (OR 2.3, 95%CI [1.5-3.8], p<0.0001) and abnormal gait speed (OR 1.9, 95%CI 1.2-3.0, p<0.01). The sFI score was not associated with deficits in the Mini-Cog (OR 1.5, 95%CI [0.96-2.3], p=0.07).Conclusion: Higher sFI was significantly associated with increased phenotypic frailty, particularly with the loss of physical condition and function but not associated with cognitive deficit. Therefore, sFI may not be an appropriate tool to estimate postoperative complications related to cognition, such as delirium risk.

•Increased odds of venous thromboembolism occurrence with increased frailty. •1.85-fold increase in venous thromboembolism odds for modified frailty index ≥3. •Frailty more strongly associated with venous thromboembolism than age. •Modified frailty index useful as venous thromboembolism risk stratification tool.

Investigations generally assess 30 days of perioperative outcomes with robotic-assisted and laparoscopic colectomy. Outcomes beyond 30 days serve as a quality metric of surgical services and an assessment of 90 days of outcomes may have greater clinical utility. The purpose of this study was to assess 90 days of outcomes, length of stay (LOS), and readmissions among patients who underwent a robotic-assisted versus laparoscopic colectomy using a national database. Patients undergoing either robotic-assisted or laparoscopic colectomy were identified using Current Procedural Terminology (CPT) codes within PearlDiver, a national, inpatient records database from 2010 to 2019. Outcomes were defined using the National Surgical Quality Improvement Program (NSQIP) risk calculator and identified using International Classification of Disease (ICD) diagnosis codes. Categorical variables were compared using chi-square tests, and continuous variables were compared using paired t tests. Covariate-adjusted regression models were also constructed to evaluate these associations while accounting for potential confounders. A total of 82,495 patients were assessed in this study. At 90 days, patients of the laparoscopic colectomy cohort experienced a higher rate of complications than patients who underwent robotic-assisted colectomy (9.5 vs. 6.6%, p < 0.001). There were no significant differences in LOS (6 vs. 6.5 days, p = 0.08) and readmissions (6.1 vs. 6.7%, p = 0.851) at 90 days. Patients undergoing robotic-assisted colectomy have a lower risk for morbidity at 90 days. Neither approach is superior for LOS nor 90 days of readmissions. Both techniques are effective minimally invasive procedures, yet patients may gain a greater risk benefit from robotic colectomy.

e16251 Background: In patients (pts) with new-onset diabetes (NOD) above the age of 50 years, 1% are diagnosed with pancreatic adenocarcinoma (PDAC) within three years. Based on this, NOD has been proposed as an important factor for early diagnosis of PDAC. Research has been directed towards investigating NOD vs Type 2 diabetes and association with PDAC. Limited data exists on its impact on the survival outcomes amongst PDAC pts. Methods: We retrospectively analyzed clinical data of 150 pts diagnosed with a pancreatic mass at three hospitals from 2014 to 2021. NOD group consisted of pts diagnosed with Diabetes or Pre-Diabetes defined as HBA1c > 6.5% and 5.7-6.4%, respectively, within the three years prior to PDAC diagnosis. Primary aim of the study was the characterization of the impact of NOD on clinical outcomes. Results: 83 pts [mean age 68.32 yrs, 58% males, 61% white] were identified with biopsy proven PDAC, out of which, 9 (11%) pts had pre-existing Diabetes, 21 (25%) pts met the criteria for NOD group. In the NOD group whose weight was available (n = 15), 11 pts (79%) had experienced weight loss within one year of the NOD diagnosis with a median age of 68.46 yrs. No significant differences were noted between race (P = 0.36), age (P = 0.9), sex (P = 0.9), tumor location (P = 0.17), and chemotherapy received (P = 0.9) between the two groups. When comparing survival outcomes, no significant differences were noted in the metastatic cohort (n = 42, PFS HR 0.77, P = 0.4, OS HR 0.9 P = 0.7) including in the subgroup analysis for pts receiving FOLFIRINOX n = 20, PFS HR 0.59, P = 0.28, OS HR 0.66 P = 0.4) or Gemcitabine based treatment (n = 9, PFS HR 1.31, P = 0.7, OS HR 0.46 P = 0.3). In the resected cohort (n = 20), pts in the NOD group did worse than pts who did not meet the criteria with PFS 10 months vs. 18.3 months (P = 0.0058, HR 7.78), a similar trend was noticed in the OS 15.2 months vs. 28.2 months (P = 0.08 HR 2.98), but it did not reach statistical significance. Conclusions: Consistent with current literature, NOD preceding PDAC is distinct from Type 2 diabetes associated NOD, characterized by weight loss and occurring at a later age. Pts with NOD preceding PDAC were shown to have worse survival outcomes in the resected cohort. Larger studies need to be conducted in this context as this could have significant implications for PDAC screening and treatment.

Introduction: The modified frailty index (mFI) is a robust predictor of postoperative outcomes for surgical patients. The present study compares the prediction effect of mFI versus age on postoperative outcomes in patients undergoing pancreatic surgery. Method: All patients who underwent pancreatic surgery were identified in the 2012–2019 National Surgical Quality Improvement Program (NSQIP). The mFI was defined by 5 variables within NSQIP. Chi-square tests were utilized to determine the associations between age, frailty, and morbidity, and mortality. Logistic regression modeling was used to evaluate these associations while adjusting for potential confounders. Results: A total of 56,465 patients were included in the study. Higher mFI and older age were both associated with a higher risk of morbidity and mortality (in univariate analysis (p<0.001). After adjustment for confounders, high mFI remained an independent preoperative predictor of postoperative mortality (OR 5.45; 95% CI [4.14-7.17]; p < 0.001) and morbidity (OR 4.72; 95% CI [4.19-5.31]; p<0.001). Older age was associated with higher risk of mortality (OR 3.52; 95%CI [1.72-7.22]; P<0.001) but not morbidity (OR 1.13; 95%CI [0.99-1.27]; p=0.22) Conclusions: Frailty is a better predictor of post-op outcomes than age, which supports the inclusion of frailty scores such as mFI in the NSQIP risk calculator and preoperative discussion with patients.

INTRODUCTION:A preoperative goals-of-care discussion is essential in maintaining the autonomy of older adults who require surgery. The purpose of this study was to determine the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) risk calculator and its association with age for patients who underwent pancreatectomy. METHODS:Using the American College of Surgeons NSQIP database, patients who underwent pancreatectomy between 2012 and 2015 were identified. Age was categorized into three groups: 18-64, 65-79, and 80-89 y. Analysis of variance and Pearson correlation coefficients were employed to assess differences between age categories in predicted and actual mortality and morbidity. Covariate-adjusted logistic regression models were employed to evaluate associations while accounting for potential confounders. RESULTS:A total of 17,906 patients were included. The correlation between actual and predicted mortality was low (r = 0.14, P < 0.001). This correlation was weakest for the age category 80-89 y (r = 0.04, P = 0.07) and strongest for 65-79 y category (r = 0.14, P > 0.001). The correlation was weakest among patients who underwent pancreatoduodenectomy (r = 0.06, P = 0.08) and in this group mortality was overestimated for older adults in the age group 80-89 (actual mortality: 3.2% versus predicted mortality: 5.6%, P = 0.08). After adjusting for covariates, the interaction term between age and predicted mortality (P = 0.0021) indicated that the relationship between predicted and actual mortality is significantly influenced by patient age. CONCLUSIONS:The NSQIP risk calculator appears to overestimate mortality and morbidity risk for elderly patients undergoing pancreatoduodenectomy. These predictions should be used with caution in preoperative goals-of-care discussions with patients aged 80 y and older.

Powell, Jocelyn DO; D'Adamo, Christopher PhD; Mavanur, Arun MD, MBBS, FACS; Svoboda, Shane MD, FACS; Demos, Jasmine S DNP, MSN, ANP-BC, RN-BC, NPFA, GCN; Katlic, Mark R. MD, MMM, FACS; Wolf, Joshua MD Author Information

Aim Emerging evidence has suggested that metformin may be protective against the development of human-papillomavirus-related cancers. Anal intraepithelial neoplasia (AIN) is highly associated with human papillomavirus infection and a precancerous status of anal cancer. The aim of this study was to investigate the relationship between metformin usage and the development of AIN in a large national sample. Methodology The IBM MarketScan dataset was used to design a nested case-control study from 2010 to 2017. Patients aged 18-65 years with type 2 diabetes mellitus (DM) were evaluated, and cases of AIN were identified. Four controls were randomly selected in the risk set of each case by using incidence density sampling. The association between metformin usage and AIN was assessed using multivariate logistic regression modelling. Results A total of 258 patients with type 2 DM were diagnosed with AIN during the study interval, and these were matched to 1032 control patients without a diagnosis of AIN. Patients who developed AIN had 38% lower odds of prior metformin use compared to those without a history of AIN (P < 0.01) and this finding remained robust after adjusting for age, sex, human immunodeficiency virus infection and DM complications (P = 0.02). Patients with AIN had 56% lower odds of long-term metformin use compared to control patients (P = 0.01). Conclusions An AIN diagnosis in patients with DM is associated with 56% lower likelihood of prior metformin use. This relationship suggests that metformin could potentially play a protective role against AIN. Prospective studies in non-diabetic patients are warranted to examine these findings further.