Abstract Introduction Minimally invasive liver surgery for hepatocellular carcinoma (HCC) is increasing. Data comparing robotic-assisted liver surgery (RALS) to laparoscopic liver surgery (LLS) for HCC remain limited. This study aimed to compare short-term and survival outcomes, following national adoption of RALS in Sweden, compared with laparoscopic (LLS) and open liver surgery (OLS). Methods Patients undergoing liver resection for HCC in Sweden between 2019‒2023 were identified in the Swedish National Quality Registry for Liver, Gallbladder and Bile Duct Cancer (SweLiv). Multiple imputation was used to handle missing data. Pairwise propensity score overlap weighting was applied to balance baseline characteristics for RALS, LLS, and OLS. Short-term outcomes were analysed using weighted logistic and linear regression models, and overall survival (OS) using weighted Cox regression. Results In total, 450 patients were included, 57 RALS, 102 LLS and 291 OLS. RALS and LLS were associated with reduced intraoperative blood loss compared with OLS (150 ml versus 400 ml, P < 0.001 and 300 ml versus 400 ml, P = 0.001, respectively). No differences were observed between RALS and LLS. Overall survival was similar across the surgical approaches, (RALS versus LLS HR 0.9, P = 0.823, RALS versus OLS HR 0.80, P = 0.538, and LLS versus OLS HR 0.72, P = 0.224). Discussion In this nationwide cohort, robotic and laparoscopic liver resections for HCC were associated with comparable perioperative and oncologic outcomes. Minimally invasive approaches reduced intraoperative blood loss compared with open surgery, without compromising short-term safety or survival. Surgical approach should primarily be guided by tumour characteristics, liver function, and local expertise.

Importance:Adjuvant chemotherapy regimens may be administered after pancreatic resection for adenocarcinoma arising from intraductal papillary mucinous neoplasms (A-IPMNs), although the evidence supporting their use is limited. Objective:To evaluate the survival benefit associated with contemporary adjuvant chemotherapy regimens after resection in A-IPMNs between 2017 and 2023. Design, Setting, and Participants:This retrospective cohort study was an international, multicenter study with 69 participating centers across Europe, North America, South America, and the Asia-Pacific region. Patients undergoing resection for A-IPMNs were included. Data were analyzed from May to August 2025. Intervention:Contemporary adjuvant chemotherapy regimens, such as gemcitabine-capecitabine (GemCap); 5-fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX), modified FOLFIRINOX (mFOLFIRINOX), and S-1. Main Outcome and Measure:Overall survival (months). Results:Among 1321 patients (median [IQR] age 70 [63 to 76] years; 713 males [54.0%] and 608 females [46.0%]), 781 patients (59.1%) received adjuvant chemotherapy, while in 181 patients (13.7%) it was omitted due to poor patient fitness. Of patients who received adjuvant chemotherapy, 568 patients (72.6%) received contemporary regimens, including GemCap (232 patients [29.7%]), FOLFIRINOX (176 patients [22.5%]), mFOLFIRINOX (71 patients [9.1%]), and S-1 (70 patients [9.0%]). The median (IQR) follow-up for the cohort was 64.2 (40.4 to 85.0) months, and the median overall survival was 73.8 months (95% CI, 66.4 to 81.9 months). After 90-day landmark analysis and exclusion of patients ineligible for chemotherapy, adjuvant chemotherapy vs no adjuvant chemotherapy (propensity score-matched populations, 243:243 patients) was not associated with improved overall survival (median, 82.3 months; 95% CI, 78.2 months to not applicable [NA] vs not reached; 95% CI, 75.3 months to NA; P = .58). Contemporary regimens vs no adjuvant chemotherapy (propensity score-matched populations, 309:309 patients) was not associated with longer survival, and a mean survival benefit greater than 4.2 months over 5 years was excluded (difference in restricted mean survival, 1.26 months; 95%, -1.72 to 4.24 months). Treatment outcomes did not vary by chemotherapy regimen or disease characteristic (eg, N stage or carbohydrate antigen 19-9 level). Conclusions and Relevance:In this study, contemporary adjuvant chemotherapy was not associated with improved overall survival in A-IPMNs, and a randomized clinical trial is indicated.

Abstract Introduction The prognosis for pancreatic ductal adenocarcinoma (PDAC) remains poor. Tumour location within the pancreas may influence resectability, metastatic patterns, and survival, potentially reflecting underlying biological differences. This retrospective study aimed to evaluate differences in protein expression between tumours of the pancreatic head and body–tail, and their associations with survival. Methods Tissue microarray specimens from 144 patients who underwent resection for PDAC were analysed using immunohistochemistry for 15 protein markers identified from prior mass spectrometry studies of proteins upregulated in pancreatic cancer. Differences in protein expression by tumour location were examined using linear regression adjusted for age, sex, AJCC 8th edition stage, and tumour differentiation. Survival was analysed using Cox proportional hazards regression with the same covariates plus adjuvant therapy. Results Body–tail tumours (n = 24) demonstrated significantly higher YAP1 expression than head tumours (n = 120), with an adjusted mean H-score difference of 30 points (95% confidence interval 1.8 to 62; P = 0.005). Body–tail location was associated with significantly worse overall survival (hazard ratio 2.0, 95% confidence interval 1.1 to 3.6; P = 0.020). Discussion PDAC arising in the pancreatic body–tail exhibited distinct protein expression patterns and was associated with worse survival compared with head tumours. Increased YAP1 expression may reflect location-specific tumour biology and a more aggressive disease phenotype.

Background:Pancreatic ductal adenocarcinoma (PDAC) is characterized by a prominent desmoplastic stroma, which plays a crucial role in tumor biology and treatment resistance. While the stromal compartment is a defining histopathological feature of PDAC, its prognostic significance remains incompletely understood. This study aimed to quantify the stromal content in PDAC using digital pathology and evaluate its association with patient outcomes. Methods:Tissue microarrays (TMAs) were constructed from resected PDAC specimens (n = 142). Digital analysis of tumor stroma percentage (TSP) was performed on tissue sections labeled with CA19-9. Cases were stratified into low and high TSP groups based on an optimized threshold of 44.2%. Associations between TSP and clinicopathological variables were assessed, and survival outcomes were analyzed using Kaplan-Meier and Cox proportional hazards models. Results:Digital quantification revealed wide intertumoral variability in TSP. A total of 127 (89%) patients were categorized into the high TSP group (>44.2% stroma). A high TSP was significantly associated with anatomic location of the tumor in the head of the pancreas. Patients with high TSP exhibited significantly prolonged overall survival (median: 27.8 months vs 12 months, p < 0.001). In multivariable analysis, high TSP remained an independent predictor of favorable prognosis (HR = 0.26, 95% CI: 0.13-0.52, p < 0.001). Conclusion:A high TSP is independently associated with improved survival in PDAC. These findings challenge traditional views of the stroma as purely tumor-promoting and suggest a potential protective role of the stromal compartment in certain contexts.

BACKGROUND:Bile leakage is a severe complication after cholecystectomy and is associated with an increased risk of morbidity and mortality. The aim of this study was to evaluate the incidence of bile leakage post-cholecystectomy and to identify potential risk factors and their association with changes in the incidence of bile leakage over time. METHODS:Demographic and perioperative data of all patients who underwent cholecystectomy in Sweden between 2006 and 2019 were retrieved from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). Data on the occurrence of bile leakage within 30 days were recorded and risk factors were identified using uni- and multivariable logistic regression analyses. RESULTS:Bile leakage occurred in 1738 of the 152,413 patients who underwent cholecystectomy, resulting in an overall incidence of 1.14%. The incidence was relatively consistent over the study period. ASA-score II and III, emergent surgery, open cholecystectomy, conversion from laparoscopic to open technique, bleeding requiring intervention, not performing, or incomplete intraoperative cholangiography (IOC) were identified as risk factors for bile leakage. The proportion of ASA II and ASA III patients undergoing cholecystectomy increased over time (p < 0.001). There was also a significant increase in the proportions of emergent cholecystectomies from 27.9% to 43.6% (p < 0.001) and surgery for complicated gallstone disease from 35.4% to 52.5% (p < 0.001) during the study period. CONCLUSION:The incidence of bile leakage was relatively consistent over the study period despite an observed increase in the prevalence of identified risk factors of bile leakage.

Combination treatments—thermal ablation (TA) and transarterial chemoembolisation (TACE) have been suggested for hepatocellular carcinoma (HCC). After TA a transient hyperemic zone appears around the ablated area, a potential target for TACE. The aim was to determine when this peri-ablational hyperemia is at its widest and most intensely perfused. This prospective study examined the hepatic peri-ablation zones with contrast-enhanced ultrasound (CEUS) in both arterial and portal venous phases, at 0, 2, 6, and 24 h after microwave ablation (MWA). Subjects were stratified into two groups, cirrhosis and non-cirrhosis. Quantitative software was used to determine relative tissue perfusion, rendering a hyperemia-to-normal liver (HTNL) ratio. The width of the hyperemic zone was measured on each arterial phase (AP). In total, 34 patients (cirrhosis n = 17, non-cirrhosis = 17) were included in this study. The hyperemia was arterially supplied with a HTNL of 567.5

Adenosquamous carcinoma of the pancreas (ASCP) is a rare and aggressive subtype of pancreatic cancer with a dismal prognosis. Futility in ASCP has been inadequately studied. The aim is to assess the incidence of futility in ASCP cases within a European cohort. Retrospective, multicenter European study including all consecutive patients who underwent surgery for ASCP between 2010 and 2024. Inclusion criteria: patients operated for ASCP during the study period. Exclusion criteria: patients without a confirmed pathological diagnosis of ASCP, those who did not undergo surgery, or had extra-pancreatic disease. A pancreatectomy was considered futile if a patient died from postoperative complications within 90 days, or if cancer-related mortality or recurrence occurred within 6 months of the operation. 194 patients from 29 hospitals in 11 European countries were studied. Surgeries included 125 pancreaticoduodenectomies, 59 left pancreatectomies, and 10 total pancreatectomies. Major complications were observed in 25.3

Abstract Introduction Portomesenteric venous resection enables curative-intent pancreatic surgery in borderline and locally advanced disease. This study aimed to investigate whether the type of venous resection influences oncological outcomes, including recurrence patterns. Methods Patients undergoing pancreatic surgery with venous resection at a single centre (2010–2022) were retrospectively analysed and stratified according to the type of venous resection—tangential or segmental. Baseline characteristics, perioperative outcomes, recurrence, and survival were assessed. Recurrence-free survival (RFS) and overall survival (OS) were estimated using Kaplan–Meier method and compared using log-rank tests. Multivariable Cox regression was performed to identify predictors of survival. Results A total of 105 patients were included (tangential n = 60, segmental n = 45). Baseline characteristics were comparable. Segmental resection was associated with longer operative time, greater blood loss, and higher transfusion rates. Major and surgical complications were similar, whereas medical complications were more frequent following segmental resection (n = 9 (15%) versus n = 15 (33%), P = 0.027). The ability to undergo adjuvant chemotherapy was comparable (n = 55 (92%) versus n = 39 (87%), P = 0.408). Recurrence patterns did not differ (P = 0.765), and RFS was similar (median 17 versus 11 months, log-rank P = 0.087). OS was also comparable (log-rank P = 0.405), with median survival of 2.4 versus 2.0 years. In multivariable analysis, venous resection type was not associated with OS (HR 0.86, 95% c.i. 0.53–1.4, P = 0.555), nor were additional extended resections (HR 0.52, 95% c.i. 0.2–1.6, P = 0.242). Discussion Segmental venous resection increases operative complexity and medical morbidity without compromising oncological outcomes, including recurrence and overall survival.

Abstract Introduction Prognosis in pancreatic ductal adenocarcinoma (PDAC) remains poor. Tumour location may affect clinical outcomes, including the ability to resect, patterns of spread, and overall survival.This study aimed to evaluate differences in survival according to location for all stages of PDAC. Methods The Swedish pancreatic and periampullary cancer registry was used to identify patients diagnosed between 2014–2023. Group differences were assessed using Kruskal-Wallis test for continuous variables and Pearson Chi-Square test for categorical variables. The hazard ratio (HR) for each tumor location was calculated using Cox regression, adjusted for age and sex. Results The final cohort included 10 763 patients with PDAC in the head (n = 6419), body (n = 2509) or tail (n = 1835) of the pancreas. Patients with tail tumours were significantly younger (median age: head 73 versus body 73 versus tail 71 years, P < 0.001). The relative rate of resection was highest for head tumours, followed by tail and body (29.8% versus 9.5% versus 13.6%, P < 0.001). Metastatic disease at diagnosis was more common in body and tail tumours (39.6% versus 69.1% versus 78.2%, P < 0.001). In multivariable Cox analysis, compared with tumours in the head, tumours in the body (HR 1.41, 95% c.i. 1.35–1.48, P < 0.001) and tail (HR 1.40, 95% c.i. 1.33–1.48, P < 0.001) were independently associated with worse survival. Discussion PDAC in the body and tail of the pancreas was associated with more advanced stage at diagnosis and worse survival than head tumors. The younger age at diagnosis may indicate the possibility of biological differences beyond delayed detection alone.

Achieving negative resection margins (R0) is central to curative surgery for pancreatic ductal adenocarcinoma (PDAC), but its prognostic relevance in multivisceral resections has been unclear. Using the largest international registry of multivisceral pancreatic resections, we performed a propensity score-matched analysis comparing R0 and R1 resections in patients undergoing multivisceral resection for PDAC. After 1:1 matching on pre- and intra-operative covariates, 222 patients were analyzed (111 R0, 111 R1). Perioperative morbidity, 90-day mortality, and intraoperative complications were comparable between groups. Median overall survival was 22.3 months after R0 resection versus 14.5 months after R1 resection; R1 status remained independently associated with poorer survival after adjustment for residual imbalances (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.02–2.07). Margin-negative resection is associated with improved long-term survival in multivisceral pancreatic surgery without an accompanying increase in perioperative risk, supporting R0 resection as a goal of surgical strategy at specialized centers.

Background: Achieving negative resection margins (R0) is considered essential for curative surgery in pancreatic ductal adenocarcinoma (PDAC). However, in the setting of complex multivisceral pancreatic resections, the prognostic relevance of margin status and its association with perioperative morbidity and long-term survival remain uncertain. We aimed to evaluate the association between resection margin status (R0 vs R1) and short-term and long-term outcomes in patients undergoing multivisceral pancreatic resections for PDAC. Methods: In this retrospective, international, multicentre cohort study, we analysed data from the largest global database of multivisceral pancreatic resections. Patients were recruited from multiple high-volume centres across several countries. Eligible participants were adults undergoing multivisceral pancreatic resection for histologically confirmed PDAC. Patients with incomplete key covariate data were excluded from propensity score matching (PSM). Clinical and pathological data were retrieved from institutional medical records and prospectively maintained databases.Propensity score matching (1:1) was performed using age, sex, body mass index, Charlson Comorbidity Index, ASA score, ECOG performance status, tumour stage, type of resection, and number of resected organs. The primary outcome was overall survival (OS). Secondary outcomes included 90-day mortality, perioperative morbidity (Clavien–Dindo classification), postoperative pancreatic fistula, delayed gastric emptying, reoperation, intraoperative complications, and ICU length of stay. Findings: After matching, 186 patients were analysed (93 R0; 93 R1). Ninety-day mortality was identical in both groups (6·5%). Rates of major morbidity, postoperative pancreatic fistula, delayed gastric emptying, reoperation, blood loss, operative time, and ICU stay were comparable between groups. Median OS was 23·6 months (95% CI 18·7–39·3) in the R0 group and 14·5 months (9·0–22·8) in the R1 group. After adjustment for residual imbalances, R1 resection was independently associated with poorer survival (HR 1·57, 95% CI 1·05–2·35; p=0·027). Interpretation: R0 resection in multivisceral pancreatic surgery is independently associated with improved long-term survival without increased perioperative morbidity or mortality. Margin-negative resection should remain the surgical goal in specialised high-expertise centres.

Abstract Introduction Pancreatic ductal adenocarcinoma is a highly aggressive malignancy. Postoperative surveillance after curative-intent surgery remains a matter of debate, without established guidelines for recommended surveillance strategies. This study aims to compare post-recurrence treatment and survival between patients with recurrence detected at scheduled controls versus due to symptoms. Methods Retrospective single-center study (2009–2023). All patients were part of a surveillance program, including computed tomography (CT) at 6, 12, 18, 24, and 36 months after surgery. Survival and treatment after recurrence were compared between patients with recurrence detected at scheduled follow-up and those detected between controls due to symptoms. Results In total 142 patients were included in the surveillance program. Patient characteristics, including tumor characteristics and neoadjuvant and adjuvant treatment, were similar in both groups. Recurrence detected by scheduled CT was associated with a greater likelihood of receiving post-recurrence treatment (84% versus 68%, P = 0.020). Median overall survival after recurrence for patients detected through scheduled radiological examination was 15 months compared to 9 months for patients detected between controls due to symptoms (15 (7–28) versus 9 (3–17), P = 0.027). For recurrence-free survival, no difference was recorded (15 (12–24) versus 16 months (10–26), P = 0.495). Discussion Patients with recurrence detected by scheduled follow-up CT were more likely to receive treatment for recurrence and also had significantly longer overall survival after recurrence compared to patients with recurrence detected due to symptoms.

BACKGROUND/OBJECTIVES:A nationwide survey, covering all surgical departments, was conducted in a country with easily accessible tax-funded healthcare. The survey aimed to provide insight into 'real-world' intraductal papillary mucinous neoplasia (IPMN) surveillance, including the proportion of patients monitored, adherence to guidelines and details of follow-up. METHODS:At all hospitals caring for IPMN patients in Sweden (n = 46), an upper-gastrointestinal surgeon received a survey by mail with clinically oriented questions, including a mix of Likert scale, multiple-choice and open-ended questions. Up to three reminders were sent. RESULTS:Forty-five hospitals responded. In median 116 (10-1500) patients with IPMN were followed at each hospital. At the hospital with the largest volume 14 physicians were involved in IPMN surveillance. In 9/45 hospitals, other professionals, such as registered nurses and secretaries, were actively involved in surveillance. All hospitals were aware of the national care program for IPMN, and all but three adhered to it. Nevertheless, uncertainty persisted about whether resources are being used wisely in branch duct (BD)-IPMN surveillance (yes/no/unsure; university hospital 2/4/0, county hospital 0/20/3 and district hospital 3/7/1). Comorbidity, older age, patient's own decision, and a combination of age and stable radiological findings were reasons for ending surveillance. Twenty-eight of 45 responders believed that surveillance will be changed in 5 years and almost all, 42/45 in 10 years. CONCLUSIONS:Adherence to the national care program for IPMN was very good, although a majority questioned the current follow-up of BD-IPMN from a resource perspective. There is a strong belief that new knowledge will change the guidelines in the near future.

Peptic gastroduodenal stenosis is a rare but disabling condition causing gastric outlet obstruction. This study aimed to evaluate endoscopic balloon dilation in terms of treatment effectiveness, durability, and identify potential early predictors of unsatisfactory outcomes. We conducted a retrospective cohort study of patients who underwent endoscopic balloon dilation for symptomatic peptic gastroduodenal stenosis at Skåne University Hospital, Lund, Sweden between January 1st, 2003, and December 31st, 2023. A total of 58 patients were included, with a median follow-up of 9.58 years [IQR 4.38–14.15]. Endoscopic balloon dilation was successful in 50 patients (86.2

Abstract Introduction Extended pancreatectomy (EP) enables resection in selected patients with locally advanced pancreatic and periampullary tumours. This study aimed to identify factors associated with overall survival following EP. Methods Consecutive patients who underwent EP for pancreatic or periampullary adenocarcinoma at a tertiary centre 2010–2022 were included. EP was defined according to International Study Group of Pancreatic Surgery (ISGPS) criteria. Data were retrieved from a national registry and supplemented by chart review. Cox proportional hazards regression was used to evaluate factors associated with overall survival (OS) in two multivariable models: one including preoperative variables and one including postoperative variables. Results A total of 125 patients underwent EP, with a median age of 70 [IQR 63–75] years, including 106 (84.8%) with venous resection. Median overall survival was 27 months, with a 3-year survival of 33%. In the preoperative model, ASA III–IV (HR 1.74, 95% c.i. 1.10–2.73), preoperative anaemia (Hb <120 g/l; HR 1.59, 95% c.i. 1.05–2.41), and diabetes mellitus (HR 1.57, 95% c.i. 1.00–2.47) were independently associated with worse survival. In the postoperative model, nodal involvement (HR 2.45, 95% c.i. 1.33–4.54), R1 resection (HR 1.71, 95% c.i. 1.12–2.62), and biliary leakage (HR 6.89, 95% c.i. 1.92–24.73) were independently associated with impaired survival. Discussion OS after EP was associated with both patient-related and tumour-related factors. Preoperative risk factors may support patient selection and optimisation, while tumour biology and postoperative complications are key determinants of outcome, highlighting the importance of both preoperative and postoperative decision-making.

Abstract Introduction Perioperative intravenous (IV) lidocaine can reduce postoperative pain, opioid use, bowel recovery time and the length of stay, but is rarely tested in liver surgery. This study evaluated the postoperative analgesic efficacy and safety of IV lidocaine in patients undergoing minor liver surgery. Methods Patients undergoing minor liver surgery were randomized 1:1 to receive either perioperative IV lidocaine, administered as a 1.5 mg/kg bolus followed by an infusion of 1.5 mg/kg/h until 1 h after surgery, or placebo. Patients received postoperative opioid analgesia via a patient-controlled analgesia device. The primary outcome was postoperative opioid consumption during the first 24 h after surgery. Secondary outcomes included postoperative pain scores, quality of recovery, adverse events, length of stay, and plasma lidocaine concentrations. Results In total, 124 subjects were included. Postoperative opioid consumption during the first 24 h after surgery was 97 (60–135) mg oral morphine equivalents (OME) in the placebo group, and 83 (50–129) mg OME in the lidocaine group, P = 0.429. Patients in the lidocaine group experienced lower early pain scores, but not from postoperative day 1 onward. Quality of recovery score did not differ, and adverse events were similar between groups. In two cases, plasma concentrations of lidocaine were transiently above 5 µg/ml after bolus administration, without clinical toxicity. Plasma concentrations after resection and at end of infusion were safely below. Discussion Perioperative intravenous lidocaine did not reduce postoperative opioid consumption after minor liver surgery but conferred transient early analgesic benefits and was found to be safe.

Abstract Introduction Venous resection is performed during pancreatic surgery to achieve cancer-free margins. This study aimed to explore the prognostic value of pre-operatively available factors for survival in patients undergoing pancreatoduodenectomy with concomitant venous resection. Methods This retrospective study used the Swedish National Pancreatic Cancer Registry to identify patients with resectable or borderline resectable pancreatic adenocarcinoma undergoing pancreatoduodenectomy in 2017–2024. Pre-operatively available patient- and disease-specific factors were compared between patients with and without concomitant venous resection using chi-square and Mann-Whitney U tests. Predictive values for survival were explored with adjusted Cox proportional hazards models. Results Among the 1626 patients included, 410 (25.2%) underwent concomitant venous resection. Patients undergoing venous resection more often had borderline tumours (19.3% versus 3.6%, P < 0.001), received neoadjuvant therapy (17.8% versus 4.9%, P < 0.001), and presented with higher baseline CA19-9 (median: 146.7 versus 85.0, P = 0.016). Postoperative pancreatic fistulae were less common among patients undergoing venous resection (5.0% versus 9.8%, P < 0.001), while post-pancreatectomy hemorrhage, bile leakage, delayed gastric emptying, and postoperative morbidity were similar between the groups. Worse survival associations were found for elevated C-reactive protein (HR 1.62; 95% c.i. 1.18–2.22, P = 0.003), diabetes (HR 1.44; 95% c.i. 1.03–2.02, P = 0.032), and pulmonary disease (chronic obstructive pulmonary disease, dyspnea at conversation and/or at rest) (HR 2.11; 95% c.i. 1.23–3.61, P = 0.006). Unintentional weight loss was associated with improved survival (HR 0.70; 95% c.i. 0.52–0.94, P = 0.019). Discussion Elevated C-reactive protein, diabetes, and pulmonary disease are associated with poor prognosis, while unintentional weight loss is associated with improved prognosis in patients undergoing venous resection.

INTRODUCTION:Resection of intraductal papillary mucinous neoplasm (IPMN) aims to prevent progression to invasive pancreatic cancer. However, the risks of pancreatic surgery and frequent findings of low-grade dysplasia (LGD) raise concerns about overtreatment. This EAHPBA-endorsed multinational study evaluated short- and long-term overall survival (OS) following preventive resection for IPMN (without pre-operative signs of cancer). METHODS:Adult patients with resected IPMN showing LGD, high grade dysplasia (HGD) or T1-staged invasive carcinoma from 2008-2023 were identified from the OPTIMAL-IPMN database. Estimated OS rates at one, five and 10 years in patients undergoing preventive pancreatic resection were assessed using Kaplan-Meier analyses and predictors for mortality were evaluated using parametric survival regressions. RESULTS:Among 2275 patients in the OPTIMAL-IPMN database, 1728 (77%) had undergone preventive pancreatic resection for IPMN. Of those were 61% resected without prior surveillance. Final pathology revealed LGD in 63%, HGD in 27% and T1a-c-staged invasive cancer in 10% (7.3% T1a-b, 2.8% T1c). Estimated 1-year OS rate was 97%. Estimated 5-year OS rates (landmark analysis at 1 year) for LGD, HGD, T1a-b, and T1c was 97%, 99%, 96% and 91% respectively. Independent predictors for long-term mortality included age ≥ 75 versus < 75 years (HR 1.97) and T1c versus LGD (HR 8.12). CONCLUSION:This multinational study confirms excellent survival after preventive IPMN resection but reveals many upfront resections yielding LGD with unknown survival benefit. Future studies should aim to determine which patients can be followed safely with monitoring to avoid unnecessary immediate resection.

BACKGROUND:Gallbladder cancer (GBC) is a rare but aggressive disease, and surgical resection remains the only potential curative treatment. Although tumour-related effects on prognosis are well established, the impact of age is less understood. This study aimed to evaluate the influence of age on overall survival (OS), recurrence-free survival (RFS), and perioperative complications in GBC. METHODS:Data from patients undergoing curative resection for GBC at 133 centres across 41 countries between 2010 and 2020 were analysed to determine the prognostic association of age ≥ 75 years with OS, RFS, and morbidity. Propensity score matching was used to address confounders between the two age groups. RESULTS:In all, 4138 patients underwent surgery for GBC. Patients with macroscopic tumour remaining after surgery, metastatic disease, only high-grade dysplasia were excluded leaving 3676 patients for analyses. Full data on all relevant parameters was available for 2072 patients aged < 75 years and 633 patients aged ≥ 75 years. Patients aged ≥ 75 years had more co-morbidities, underwent less extensive surgery or lymphadenectomy, and received adjuvant chemotherapy less frequently than younger (< 75 years) patients. Age ≥ 75 years was associated with poorer OS in both the unmatched (hazard ratio (HR) 1.34; 95% confidence interval (c.i.) 1.14 to 1.56; P < 0.001) and matched cohorts (HR 1.31; 95% c.i. 1.12 to 1.54; P < 0.001) cohorts, but was not associated with RFS or 1-year survival. Tumour extent and nodal stage had the greatest association with OS and RFS. Age was not associated with increased complications in either the unmatched (odds ratio (OR) 1.11; 95% c.i. 0.85 to 1.45; P = 0.400) or matched (OR 0.90; 95% c.i. 0.72 to 1.12; P = 0.353) cohorts. CONCLUSIONS:Older adults received less extensive surgery and infrequent adjuvant chemotherapy. Age ≥ 75 years was associated with poorer OS following GBC resection but comparable complication rates to younger adults. Older adults of sufficient fitness should not be denied curative treatment based on age, and oncological benefit should be balanced against perioperative risk to personalize treatment and optimize surgical outcomes.