BACKGROUND:Suturing complex anastomoses requires repetitive training for mastery. Expert tutoring is a limited and costly ressource. This study assessed the added value of surgical video instructions in expert-tutored hepatopancreatobiliary (HPB) surgery courses. METHODS:Trainees and tutors used QR codes to access instructional videos of pancreatico- and hepaticojejunostomy (04/2024-09/2025: Davos course for HPB Surgery; Hands-On- Course of the North-German Surgical Association; ESSO Course Pancreatic Surgery). After watching videos and performing anastomoses on 3D-biotissue organ models, participants anonymously completed standardized questionnaires. RESULTS:Out of 51 participants (20 residents; 31 specialists), most reported that QR codes facilitated video access (n=48, 96%). The majority found the videos useful (n=31, 62%). Most preferred a combination of expert tutoring and surgical video instructions (n=49, 96%) and agreed that expert tutoring was more effective when supported by videos (n=44, 86%). Furthermore, 28 (55%) participants felt they could improve their surgical skills with the videos in self-directed training without expert guidance. Older and more experienced participants were more likely to agree that videos added value to expert tutoring. CONCLUSION:Surgical video instructions were well accepted and perceived as valuable additions to expert-tutored courses on HPB anastomoses. Further studies should assess translation into improved training outcomes.

BACKGROUND:Length of hospital stay (LOS) is a commonly reported postoperative outcome measure in pancreatic surgery. However, LOS may be influenced by various factors, including healthcare systems, cultural traditions, and readmission rate. This systematic review and meta-analysis investigated LOS in pancreatic surgery. METHODS:A meta-analysis was conducted to identify all randomized clinical trials (RCTs) of pancreatic surgery reporting LOS. Analyses were conducted using a random-effects model with mean differences as the effect estimator for the continuous outcome LOS. RESULTS:In all, 186 RCTs published between 1994 and 2025, comprising 28 381 patients, were included. The mean LOS differed significantly by type of resection (P = 0.003) and by country (P < 0.001). Country remained a statistically significant factor after adjusting for readmission rate, year of study, and type of resection. The shortest LOS was observed in the USA, with a pooled value of 11 days (95% confidence interval (c.i.) 9.93 to 12.32) and the longest was seen in Japan, with a pooled value of 28 days (95% c.i. 25.60 to 31.67). Subgroup analysis of studies comparing minimally invasive and open surgery showed a mean LOS difference of 2 days (95% c.i. -2.79 to -0.85; prediction interval -7.70 to 4.06). However, this effect varied across countries, with mean LOS differences ranging from 1 to 6 days. CONCLUSION:LOS after pancreatic surgery exhibited substantial statistical heterogeneity based on country, the type of operation, and access. This highlights the importance of considering contextual factors when evaluating and comparing LOS as an outcome measure in pancreatic surgery.

BACKGROUND:Venous congestion and small bowel edema after venous reconstruction during pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) may compromise anastomotic safety. A two-stage approach with delayed gastrointestinal reconstruction may offer a protective strategy. We refer to this concept as the TARP procedure (Two-stage Anastomotic Reconstruction after Pancreatectomy). MATERIALS AND METHODS:This retrospective single-center study analyzed all consecutive patients who underwent TARP between February 2023 and February 2025. Tumor resection and venous reconstruction were completed in an initial operation, followed by deferred reconstruction within 24-72 h. Baseline characteristics and perioperative outcomes were analyzed descriptively. RESULTS:Nine patients underwent TARP during the study period. The median age was 72 years and the primary indication for a two-stage reconstruction was small bowel edema due to venous congestion. Median operation time was 401 min, median ICU stay 9 days, and median hospital stay 28 days. No patient developed an anastomotic leak or clinically relevant postoperative pancreatic fistula. Six patients (66.7%) experienced Clavien-Dindo grade ≥ IIIb complications. One patient (11.1%) died within 30 days. CONCLUSIONS:Two-stage PD with delayed reconstruction appears to be a feasible approach in selected patients with intraoperative risk factors such as bowel edema or instability. Avoiding anastomosis under unfavorable conditions may reduce early morbidity.

Rectal neuroendocrine tumors (rNET) are rare but increasingly more common entities, which are usually an incidental finding during routine colonoscopy. The rNETs are usually well-differentiated with low metastatic potential. Thus, staging is only required in high-risk situations (size ≥ 10 mm, invasion of the muscularis propria, grading > G1, L1, V1). Endoscopic resection is the most frequently used treatment. Based on the depth of invasion, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD) or endoscopic full-thickness resection (EFTR) are applied. In cases of R1 resection, re-endoscopic resection can be conducted to achieve R0 status. Radical surgical resection with higher or lower anterior rectum (HAR/LAR) resection with total mesorectal excision (TME) is indicated for rNETs > 20 mm, rNETs between 10-20 mm with risk factors (R1 resection after second endoscopic resection, Ki67 > 10%, L1, V1), lymph node metastasis and also in cases of distant metastasis if those are also resectable. In cases of unresectable distant metastasis, systemic treatment is applied. The prognosis after treatment of well-differentiated rNETs is generally favorable.

Most minimally invasive surgery (MIS) training curricula involve practical training (PT) and cognitive learning (CL) to different extents. It has been proven that acquiring and training specific skills through CL can improve MIS skills. This study aimed to discover the most efficient combination of these two approaches and examine their effects on acquiring MIS skills in novices. Sixty medical students without MIS experience participated in this randomized controlled study and were divided into three groups. The first group received the same amount of PT (50

OBJECTIVE:Optimal treatment strategies for small (≤2 cm) nonfunctioning pancreatic neuroendocrine neoplasms are still subject to discussion. The aim of this study was to analyze real-world data of patients with pancreatic neuroendocrine neoplasms ≤2 cm regarding the indications for surgery and long-term postresection survival. METHODS:All patients undergoing surgery for nonfunctioning pancreatic neuroendocrine neoplasms ≤2 cm between 2003 and 2023 were analyzed. Indications for surgery, clinicopathologic parameters, and long-term survival were assessed. Differences between pancreatic neuroendocrine neoplasms <1 cm and 1-2 cm were evaluated. RESULTS:Of a total of 806 resected pancreatic neuroendocrine neoplasms, 237 patients had a lesion ≤2 cm (29.4%), 85 of which were smaller than 1 cm. The 3 most common indications for surgery for pancreatic neuroendocrine neoplasms ≤2 cm were either suspicion of a non-neuroendocrine neoplasm malignancy (55.2%), suspicion of neuroendocrine tumor (25.9%), or obstruction of the pancreatic duct (9.4%). Tumor differentiation was 84% G1, 15% G2, and 1.3% G3. Noticeably, 5.1% of pancreatic neuroendocrine neoplasms ≤2 cm had lymph node metastasis (pN1). Five patients with a small pancreatic neuroendocrine neoplasm developed distant metastasis (pM1). The 10-year overall survival was 86.9% for <1 cm and 84.5% for 1-2 cm (P = .964). 10-year disease-free survival was 83.1% in patients with a pancreatic neuroendocrine neoplasms <1 cm and 81.1% for pancreatic neuroendocrine neoplasms 1-2 cm (P = .784). CONCLUSION:Surgical treatment of small (≤2 cm) pancreatic neuroendocrine neoplasms provides excellent long-term survival. Since even small pancreatic neuroendocrine neoplasms can develop lymph node and distant metastases, treatment decisions should not be determined on the basis of tumor size alone.

Background:Pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal malignancies, with early detection and surgical resection being the only potentially curative treatment option. Despite advancements in diagnostics and surgical techniques, the prognosis of early-stage PDAC remains poor. Understanding the indications, approaches and perioperative management are crucial for improving patient survival. Summary:Surgical resection remains the only curative treatment for early-stage PDAC. Different surgical procedures are performed depending on tumor location and local extent. Advances in minimally invasive surgery (MIS) yielded promising results regarding postoperative recovery and oncologic outcomes. The implementation of neoadjuvant therapy has improved resection and survival rates. Still, pancreatic surgery is associated with significant morbidity. Key Messages:Surgical resection remains the only curative option for early-stage pancreatic cancer. Neoadjuvant chemotherapy plays a crucial role in improving resection and survival rates. Perioperative care has been refined by MIS, optimized surgical techniques, and structured complication management.

Minimally invasive surgery (MIS) is the standard approach in bariatric surgery. The most common bariatric procedures are sleeve gastrectomy and Roux-en-Y-Gastric Bypass (RYGB). Simulation training, including virtual reality (VR), is useful when learning MIS. Training in pairs has proven beneficial in acquiring basic MIS skills. However, this has not been tested on more complex procedures such as MIS RYGB. The study aimed to assess the learning effects of training MIS RYGB on a VR trainer in pairs compared to solo training. Medical students (n = 60) were randomized into the intervention group, trained in pairs (n = 30), and the control group, trained solo (n = 30). Both groups needed to train MIS RYGB on a VR trainer under the supervision of trained tutors until proficiency was reached. The MIS RYGB proficiency was defined as 105/110 points according to the Bariatric Objective Structured Assessment of Technical Skills (BOSATS) score. The primary outcome was the number of exercise repetitions until proficiency was reached. Secondary outcomes compared the BOSATS scores, bleeding incidents, and the validated score on current motivation. The intervention group achieved proficiency with significantly fewer repetitions than the control group (p = 0.002). Most participants in the intervention group reached proficiency by the fifth repetition, and none required an eighth repetition. The intervention group had better BOSATS scores than the control group after the second, fourth, and fifth MIS RYGB (91.1 ± 6.4 vs. 87.1 ± 7.0 points, p = 0.025; 104.0 ± 4.7 vs. 100.3 ± 6.1 points, p = 0.014; 106.2 ± 2.8 vs. 101.9 ± 5.8 points, p = 0.026), respectively. Additionally, the intervention group experienced fewer bleeding complications in the fifth and sixth MIS RYGB repetitions than the control group (2 vs. 10, p = 0.001; 0 vs. 8, p < 0.001, respectively). Training MIS RYGB on a VR trainer in pairs enables trainees to reach procedural proficiency with fewer exercise repetitions than training alone.

Background/Objectives: Insulinomas are rare insulin-secreting pancreatic neuroendocrine tumours (pNETs). Preoperative tumour localisation can usually be achieved by computed tomography (CT), magnetic resonance imaging, or positron emission tomography (PET)-CT. However, cross-sectional imaging can be negative, defining an insulinoma as occult and thus hampering surgical resection. Methods: All patients who underwent minimally invasive (MI) surgery for an insulinoma at the University Medical Center Hamburg-Eppendorf since 2017 were analysed. Clinicopathological parameters and diagnostic and operative approaches were assessed. A literature search of the MI resection of occult insulinomas was conducted. Results: Of eight patients with MI-resected insulinomas, two (25%) had negative preoperative imaging. Mean tumour size was 17.2 ± 13.3 mm. Patients underwent distal pancreatectomy (DP), enucleation, and pancreatic head resection (PHR) in 62.5% (5/8), 25.0% (2/8), and 12.5% (1/8) of cases, respectively. One patient had a major postoperative complication (Clavien–Dindo ≥ 3a). Twenty-four studies reporting on 140 occult insulinomas were identified. Occult insulinomas were more frequent in females, often located in the distal pancreas and G1-differentiated. Glucagon-Like Peptide-1 Receptor/PET-CT most frequently localised the conventionally non-visible insulinomas (positive in 67/76, 88.2%). Enucleation, DP, PHR and other resections were conducted in 47/94 (50.0%), 40/94 (42.6%), 4/94 (4.3%), and 3 (3.2%) of the reported cases. MI resection was reported in 10 of 19 (52.6%) specified resections. Conclusions: Insulinomas can be undetectable in cross-sectional and functional imaging. Surgical exploration with intraoperative ultrasound should be considered when clinical presentation and biochemical findings are highly suggestive for insulinoma. Minimally invasive and parenchyma sparing resection is feasible even for occult insulinomas and should always be considered.

Splenic-artery aneurysms (SAAs) are rare but potentially life-threatening vascular lesions with a high risk of rupture, especially when symptomatic or thrombosed. Timely diagnosis and appropriate intervention are essential to prevent fatal haemorrhagic events. This case report details the management of a 60-year-old male with a giant SSA, emphasizing the necessity of urgent surgical intervention and the advantages of an open approach for rapid vascular and haemorrhage control. The patient presented with progressive upper abdominal discomfort. Computer tomography revealed a 10 × 10 cm thrombosed SAA compressing the pancreatic tail. Due to high rupture risk, open distal pancreatosplenectomy was performed. Postoperatively, the patient remained haemodynamically stable without complications or need for re-intervention. This case demonstrates the critical importance of open surgery in managing giant SAAs, offering direct vascular access and effective bleeding control. Early diagnosis and prompt surgical intervention are paramount in managing symptomatic SSA.

Neuroendocrine tumours (NET) are rare entities arising from hormone producing cells in the gastroentero-pancreatic (GEP) tract. Surgery is the most common treatment of GEP-NETs. Improvements in surgical techniques allow for more locally advanced and metastasised GEP-NETs to be resected. Laparoscopic and robotically–assisted approaches are increasingly being utilised in the resection of selected GEP-NETs and are facilitated by novel intraoperative tumour localisation tools and parenchyma-sparing methods. At the same time, some authors suggest that indications for formal resections of small well differentiated non-functioning pancreatic NETs and appendiceal NETs should be more restrictive. Advancements in surgery allows for tissue-sparing resections of GEP-NETs. Indications for surgical resection and the extent of the procedure are highly dependent on GEP-NET size, localisation and grading. Robotically assisted surgeries with intraoperative ultrasound and visualisation methods as well as vessel-sparing radical retrograde lymphadenectomies for small intestinal NETs seem to be the future of GEP-NET surgery.

Background: Surgery offers the only cure for borderline resectable or locally advanced pancreatic neuroendocrine neoplasms. Data on incidence, perioperative and long-term outcomes of portal vein resection for pancreatic neuroendocrine neoplasms are scarce. This study aimed to analyze the outcome and prognostic factors of portal vein resection in surgery for pancreatic neuroendocrine neoplasms. Methods: Consecutive patients were analyzed. Portal vein resection was classified according to the International Study Group of Pancreatic Surgery. Clinicopathologic features and overall and disease-free survival were assessed and compared with standard resection in a matched-pair analysis. Results: A total of 54 of 666 (8%) resected pancreatic neuroendocrine neoplasms patients underwent portal vein resection, including 7 (13%) tangential resections with venorrhaphy (type 1), 2 (4%) patch reconstructions (type 2), 35 (65%) end-to-end anastomoses (type 3), and 10 (19%) graft interpositions (type 4); 52% of those underwent pancreatoduodenectomy, 22% distal pancreatectomy, and 26% total pancreatectomy. Postoperative portal vein thrombosis occurred in 19%. Postoperative pancreatic fistula grades B and C (9% vs 16%; P = .357), complications Clavien-Dindo grade >= IIIb (28% vs 13%; P = .071), and 90-day mortality rate (2% each) were not significantly different compared with 108 matched patients. The 5-year overall survival was 45% (standard resection: 68%; P = .432), and the 5-year disease-free survival was 25% (standard resection: 34%; P = .716). Radical resection was associated with 5-year overall survival of 51% and 5-year disease-specific survival of 75%. Conclusion: This is the largest single-center analysis evaluating perioperative and long-term outcomes of portal vein resection for pancreatic neuroendocrine neoplasms. The postoperative complication rate after portal vein resection is comparable with standard resection. The 90-day mortality is low. Radical resection leads to excellent 5-year oncological survival.

INTRODUCTION:Nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) have been diagnosed increasingly often but still represent rare pancreatic neoplasms. Surgery is a potentially curative approach for patients with NF-PNETs. In recent years, minimally invasive surgery (MIS) has been applied more frequently for surgical resection of NF-PNETs. The evidence for using MIS for NF-PNETs is still being determined and controversial. MATERIALS AND METHODS:PubMed, Cochrane Library, and the Web of Science database were searched systematically from its inception to July 2023. All studies comparing MIS versus open surgery (OPS) of NF-PNETs were included. The primary outcomes were the incidence of overall postoperative complications and pancreas-specific complications [postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE)]. The secondary measures were duration of operation, intraoperative blood loss, and length of postoperative hospital stay. Pooled results are presented as odds ratios (OR) or mean difference (MD) with a 95% CI. RESULTS:Five observational studies with a total of 1178 patients were included in the final analysis. The meta-analysis indicated that MIS attained less intraoperative blood loss (MD=-58.59, 95% CI [-92.76 to -24.41], P<0.01) and shorter length of hospital stay (MD=-3.07, 95% CI [-5.28 to -0.87], P<0.01) in contrast to open surgery for NF-PNETs. There were no significant differences concerning operative time (MD=52.04, 95% CI [-8.74 to 112.81], P=0.67), overall postoperative complications (OR=0.78, 95% CI [0.59-1.03], P=0.08), POPF (OR=0.99, 95% CI [0.66-1.47], P=0.94), and DGE (OR=0.58, 95% CI [0.58-1.42], P=0.67). CONCLUSIONS:This study demonstrates that minimally invasive surgery for NF-PNETs is safe and associated with a considerably shorter postoperative hospital stay. Further studies are needed to verify the evidence.

Objective: The goal of the current study was to investigate the perioperative outcomes of robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) in a high-volume center. Summary Background Data: Despite RPD’s prospective advantages over OPD, current evidence comparing the two has been limited.and has prompted further investigation. The aim of this study was to compare both approaches while including the learning curve phase for RPD. Methods: A 1:1 propensity score-matched (PSM) analysis of a prospective database of RPD with OPD (2017-2022) at a high-volume center was performed. Main outcomes were overall- and pancreas specific complications. Results: Of 375 patients who underwent PD (OPD n=276, RPD n=99), 180 were included in PSM analysis (90 per group). RPD was associated with less blood loss (500 (300-800) vs. 750 (400-1000)ml; P =0.006) and less total complications (50% vs. 19%; P <0.001). Operative time was longer (453 (408-529) vs. 306 (247-362)min; P <0.001); in patients with ductal adenocarcinoma, fewer lymph nodes were harvested (24 (18-27) vs. 33 (27-39); P <0.001) with RPD versus OPD. There were no significant differences for major complications (38 vs. 47%; P =0.291), reoperation rate (14% vs. 10%; P =0.495), postoperative pancreatic fistula (21% vs. 23%; P =0.858) and patients with textbook outcome (62% vs. 55%; P =0.452). Conclusions: Including the learning phase, RPD can be safely implemented in high-volume settings and shows potential for improved perioperative outcomes versus OPD. Pancreas-specific morbidity was unaffected by the robotic approach. Randomized trials with specifically trained pancreatic surgeons and expanded indication for the robotic approach are needed.

Background A direct comparison of the cost–benefit analysis of retroperitoneoscopic adrenalectomy (RPA) versus the minimally invasive transperitoneal access (LTA) approach is currently lacking. We hypothesized that RPA is more cost effective than LTA; promising significant savings for the healthcare system in an era of ever more limited resources. Methods We performed a monocentric retrospective observational cohort study based on data from our Endocrine Surgery Registry. Patients who were operated upon between 2019 and 2022 were included. After pair-matching, both cohorts (RPA vs. LTA) were compared for perioperative variables and treatment costs (process cost calculation), revenue and profit. Results Two homogenous cohorts of 43 patients each (RPA vs. LTA) were identified following matching. Patient characteristics between the cohorts were comparable. In terms of both treatment-associated costs and profit, the RPA procedure was superior to LTA (costs: US$5789.99 for RPA vs. US$6617.75 for LTA, P = 0.043; profit: US$1235.59 for RPA vs. US$653.33 for LTA, P = 0.027). The duration of inpatient treatment and comorbidities significantly influenced the cost of treatment and the overall profit. Conclusions RPA appears not only to offer benefits over LTA in terms of perioperative morbidity and length of hospital stay, but also has a superior financial cost/benefit profile. Graphical abstract

Cystic lesions of the pancreas are a very heterogeneous group of tumors, with about 35% being intraductal papillary mucinous neoplasms (IPMN). IPMN are believed to be associated with a field defect, in which the entire ductal system of the pancreas is at risk of developing neoplasia. There is also a risk of concomitant pancreatic ductal adenocarcinoma and a higher risk of extrapancreatic invasive lesion development in patients with IPMN. Recurrence rates for resected invasive IPMN are reported up to 34% and for resected noninvasive IPMN between 1% and 20%. Recurrence rates of secondary invasive lesions after surgical resection of a noninvasive IPMN are reported between 2% and 7%. Whilst the five-year recurrence-free survival rates have been reported to be favorable (between 77% to 100%), the median time to recurrence has been described to range from 15 months to 4.5 years. The cumulative 10-year risk of development of a new invasive pathology has been described as up to 38%. Specific risk factors associated with a higher risk of recurrence are positive family history, high-grade dysplasia in the resected specimen, and positive resection margins. Concomitant low-risk lesions in the remnant pancreas have been reported between 7% and 20%. These do not seem to have an increased risk of progression or recurrences, but literature on this topic is quite scarce also due to the fact that the terms “progression” and “recurrence” are not used consistently in many analyses. All published guidelines agree on life-long surveillance after resection of IPMN of the main duct or with high-grade dysplasia. Recommendations for follow-up of patients undergoing surgery for low-grade or intermediate-grade IPMN, however, are still subject to discussion and no formal gold standard exists. This chapter focuses on the risk of recurrence of IPMN and postoperative surveillance strategies.