BACKGROUND:Surgery for pancreatic cancer is associated with postoperative venous thromboembolism (VTE) rates of 5% to 20%, prompting the routine use of extended VTE chemoprophylaxis. The incidence and predictors of VTE after chronic pancreatitis (CP) surgery remain unclear. METHODS:Retrospective single-institution analysis of postsurgical patients for CP between January 2007 and June 2025. Postoperative VTE rates at 90 days were evaluated, including extremity deep vein thrombosis (DVT), pulmonary embolism (PE), and mesenteric vein thrombosis (MVT). Perioperative definitions aligned with the American College of Surgeons National Surgical Quality Improvement Program and the International Study Group for Pancreatic Surgery. RESULTS:A total of 739 patients underwent surgery for CP. Venous thrombosis developed in 50 (6.8%) patients. Postoperative DVT/PE was diagnosed in 22 (3.0%) patients on postoperative day 23 ± 20. Multivariable regression found higher body mass index, lower serum albumin, and longer operative time to be risk factors for DVT/PE. Major morbidity was higher in patients who developed DVT/PE (86.3% vs 40.2%; P <.001); however, mortality was similar between groups (0% vs 0.6%; P =.7). Postoperative MVT was diagnosed in 33 (4.5%) patients on postoperative day 23±18. Multivariable regression found organ-space infection and postpancreatectomy hemorrhage to be risk factors for MVT. Major morbidity (81.8% vs 39.7%; P <.001) and mortality (6.1% vs 0.4%; P =.0001) were higher in patients who developed MVT. CONCLUSIONS:Extremity DVT, PE, and/or MVT occurred in 6.8% of patients who underwent surgery for CP and impacted postoperative morbidity and mortality. Given this high-risk population, prospective studies optimizing strategies for postoperative chemoprophylaxis are warranted and should consider extended chemoprophylaxis and weight-based dosing.

Historical pediatric data recommend surgical resection for type I choledochal cysts because of the risk of malignant progression over time (up to 60

The operative management of duodenal tumors remains controversial with outcomes comparing pancreatoduodenectomy (PD) versus duodenectomy arising from small, noncontemporary cohorts. The aim of this study is to examine perioperative outcomes between PD and duodenectomy for duodenal masses. It is hypothesized that the morbidity profile of a duodenectomy lies between that of a PD and that of an enterectomy for a distal small bowel tumor. A single-institution retrospective review was performed of patients with non-ampullary duodenal tumors who underwent PD or duodenectomy between 2006 and 2025. Duodenectomy was classified as proximal (D1/D2) versus distal (D3/D4) duodenectomy based on tumor location. Patients who underwent enterectomy for jejunal/ileal tumors were identified as another comparison group. The primary outcome was 30-day major morbidity, defined as a composite of core complications (delayed oral feeding autonomy, abscess, anastomotic leak, bleeding requiring intervention, reoperation) and was evaluated across four cohorts: PD vs. proximal duodenectomy vs. distal duodenectomy vs. enterectomy. The analytic cohort consisted of 235 patients: PD = 86 (36.6

Bile duct injuries (BDI) are a rare but serious complication of cholecystectomy, associated with substantial morbidity and clinical burden. However, no consensus has been reached on the optimal surgical approach for the management of BDI. This meta-analysis aims to evaluate the safety and efficacy of minimally invasive surgery (MIS) for the repair of iatrogenic BDI. Cochrane, CINAHL, Ovid Embase and Medline were searched from their inception date to March 2025. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines were followed. The review was registered prospectively on PROSPERO (CRD420251009530). A total of 246 patients with MIS for BDI repair from sixteen studies were included in the analysis. The pooled mean operative time was 219 min (95

Backgrounds/Aims:The impact of cirrhosis on outcomes following minimally invasive liver resection (MILR) remains debated. This meta-analysis evaluates the effect of cirrhosis on perioperative outcomes in patients undergoing MILR. Methods:PubMed, Embase, CINAHL, Scopus, and Web of Science were searched from inception to September 17, 2025, following PRISMA guidelines (PROSPERO: CRD420251132827). Results:Thirty-two studies, comprising 12,892 patients (5,658 with cirrhosis; 7,234 without), were included. Cirrhosis was associated with higher intraoperative transfusion rates (odds ratio [OR] = 1.55; 95% confidence interval [CI] 1.17-2.05), conversion to laparotomy (OR = 1.24; 95% CI 1.05-1.47), 90-day morbidity (OR = 1.38; 95% CI 1.04-1.83), and 90-day mortality (OR = 1.82; 95% CI 1.24-2.67). Thirty-day morbidity and mortality were similar between groups. Child-Pugh B patients had higher transfusion rates than Child-Pugh A patients (OR = 1.48; 95% CI 1.10-2.00), and portal hypertension was associated with higher conversion rates (OR = 1.66; 95% CI 1.12-2.46). Conclusions:In carefully selected patients, predominantly Child-Pugh A, treated at high-volume centers, cirrhosis was associated with higher rates of conversion to laparotomy, intraoperative transfusion, and 90-day morbidity and mortality. However, the serious risk of bias across the included studies limits the certainty of these associations.

Bile leak (BL) remains one of the major adverse events of hepatobiliary surgeries. We evaluated ERCP outcomes for postoperative BL (PBL) cholecystectomy (C-BL), hepatectomy (H-BL), and liver transplantation (LT-BL) and identified predictors of persistent leak after initial ERCP. This study includes consecutive patients who underwent ERCP for PBL at a single high-volume center (2011–2021). Leaks were graded as low-grade BL (LG-BL) or high-grade BL (HG-BL). Initial success was defined as cholangiographic and clinical resolution of BL following a single therapeutic ERCP session at the first follow-up ERCP. Final success was defined as cholangiographic and clinical resolution of the BL at the last follow-up assessment, irrespective of the number of therapeutic ERCP sessions required. 417 patients with PBLs were included: 348 (83.5

BACKGROUND:Postpancreatectomy acute pancreatitis (PPAP) is an increasingly recognized but still disputed clinical entity. Defined by the International Study Group for Pancreatic Surgery in 2022 as a 48-hour postoperative elevation of serum amylase level and radiographic confirmation of pancreatitis. PPAP is graded as postoperative hyperamylasemia (POH), grade B, and grade C. The 2023 National Surgical Quality Improvement Program's (NSQIP) pancreatectomy-targeted Participant Use Data File included for the first time PPAP variables. This study aimed to determine whether the NSQIP data will reflect the incidence of PPAP in a national sample. METHODS:Patients who underwent a pancreatectomy at 168 participating institutions between January 1, 2023, and December 31, 2023, were included in the NSQIP pancreatectomy-targeted dataset. Cases were identified using Current Procedural Terminology codes. The variables were captured retrospectively. Data were amassed and managed by the American College of Surgeons NSQIP. RESULTS:Of 8015 patients included in the analysis, 1273 (17%) had amylase values. Among these patients, 782 (61%) had normal serum amylase level, 430 (34%) had POH, 53 (4.1%) had grade B PPAP, and 8 (0.01%) had grade C PPAP. Multivariable logistic regression found a small pancreatic duct and soft pancreatic texture to be significantly associated with POH and clinically relevant PPAP (CR-PPAP) for head resections. Patients with POH and CR-PPAP were significantly more likely to have any-cause morbidity and complications, such as Clavien-Dindo grade ≥ 3 (P <.05 and P <.05, respectively). CONCLUSION:This is the first national survey of patients who underwent pancreatectomy that confirmed a high incidence of POH and PPAP. The low rate of amylase level measurement suggests that general education about this disease process will be important. Normal pancreatic texture is the most significant risk factor for developing POH/PPAP, and mitigation strategies and more liberal use of early postoperative imaging should be considered for patients.

BACKGROUND:Laparoscopic subtotal cholecystectomy (STC) is an established approach for difficult cholecystectomy (CCY) and a well-recognized strategy to mitigate complications such as bile duct injury. The incidence of post-CCY bile leak is higher after STC than after total CCY (TC). Endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy and bile duct stent placement is the standard, effective therapy for bile leaks after CCY. With the increasing adoption of STC as a strategy for complex CCY, a comprehensive understanding of ERCP's effectiveness for a bile leak after STC is imperative. We performed a comparative analysis of patient characteristics, periprocedure details, and clinical outcomes in patients who underwent ERCP for bile leak after STC vs TC. METHODS:Data from patients referred for ERCP at Indiana University Health Hospital between 2011 and 2021 were collected within a retrospective database. Patients with Strasberg Type A bile leaks and/or leak from the gallbladder remnant were included in the analysis. Patients with bile leaks with etiologies other than CCY (eg, hepatectomy or trauma) or additional CCY-related complications (eg, common bile duct injury) were excluded. Operative reports, ERCP cholangiogram findings, and post-CCY cross-sectional imaging were reviewed to verify TC or STC status. High-grade bile leaks were defined as evidence of contrast extravasation before opacification of the intrahepatic ducts on retrograde cholangiogram. Outcomes evaluated included resolution of the bile leak at the first postintervention follow-up ERCP (via biliary sphincterotomy or stent insertion), the total number of ERCP procedures required for resolution, and the overall success of ERCP for leak resolution. RESULTS:Among patients with bile leak, 301 met study criteria. Patients who underwent STC were older, had a higher body mass index, and were more often male. Patients who underwent STC more frequently had a drain in place at the time of the first ERCP (P <.001) and less often had a biloma (P =.009). Patients who underwent STC were more frequently treated with the placement of self-expanding metal biliary stents (SEMS) (P =.001) and had a longer stent dwell time after the index ERCP (41 vs 35 days; P =.02). The overall success rate for leak resolution was high with ERCP (98%). Although there was a trend toward a higher rate of leak resolution at the first follow-up ERCP among TC patients (P =.07), the total number of ERCP procedures and the overall success of ERCP in managing post-CCY bile leak did not differ between the 2 groups. CONCLUSION:ERCP remains an effective strategy for the management of bile leak after CCY, including in patients experiencing bile leak as a complication of STC. In our cohort, strategies such as SEMS placement and extended stent dwell time were more frequently employed in patients who underwent STC at the discretion of the endoscopist. Despite this, no differences in ERCP procedure burden or rates of bile leak resolution were observed between TC and STC patients.

OBJECTIVE:To evaluate perioperative morbidity and mortality outcomes in a large, contemporary series of patients undergoing pancreas head resection for chronic pancreatitis. SUMMARY BACKGROUND DATA:Select chronic pancreatitis (CP) patients benefit from pancreatic head resection, but contemporary data are sparse. Anatomy dictates selection of duodenum-preserving pancreatic head resection (DPPHR) or pancreatoduodenectomy (PD). We hypothesized that both DPPHR and PD are safe in select patients. METHODS:CP patients undergoing pancreas head resection from 2007-2023 at a high-volume institution were analyzed. Patient comorbidities, operative data, and postoperative 30-day outcomes were defined according to National Surgical Quality Improvement Program (NSQIP) and International Study Group on Pancreatic Surgery (ISGPS). Preoperative and intraoperative variables between groups were compared. Continuous data are presented as median [interquartile range]. RESULTS:Among 338 patients (50% female), 252 underwent PD and 86 DPPHR (69 Frey, 11 Beger, 4 Izbicki, 2 Bern). Median age was 52[17] years (PD 53.1[17], DPPHR 50.1[20], P=0.036). Preoperative tobacco use (57%) and diabetes (27%) were common. The PD group had longer operative times (282[131] vs. 207.5[91] minutes, P<0.001) and higher intraoperative blood loss (307.5[400] vs. 100[200] milliliters, P<0.001). Median length of stay was 8[6] days (PD 8[6.3], DPPHR 7[4]). Major morbidity occurred in 22% of patients (PD 23%, DPPHR 21%). At 30 days, the readmission rate was 17% (PD 17%, DPPHR 17%) and mortality occurred in 1.2% (PD 1.6%, DPPHR 0%). CONCLUSIONS:This large, contemporary analysis demonstrated safety of pancreatic head resection in select CP patients.

BACKGROUND AND OBJECTIVES:Adjuvant chemotherapy (AC) is considered for patients with stage II small bowel adenocarcinoma (SBA) with an inadequate lymphadenectomy; however, the prognostic role of additional high-risk features (T4 primary, positive resection margin, poorly differentiated tumor, or lymphovascular invasion) is unknown. The objectives were to describe utilization of AC among patients with stage II SBA with inadequate lymphadenectomy, identify factors associated with receipt of AC, and examine the association between AC and survival stratified by presence of additional high-risk features. METHODS:Patients with stage II SBA were identified using the National Cancer Database from 2004 to 2021. Inadequate lymphadenectomy was defined < 5 lymph nodes duodenal tumors and < 8 lymph nodes other sites. RESULTS:Of 1765 patients with stage II SBA and an inadequate lymphadenectomy, 525 (29.8%) received AC. T4 primary, poor grade tumor, and positive resection margin were associated with receiving AC. Receipt of AC was associated with improved 5-year survival in patients with additional high-risk features (49.9% vs 31.4%; HR 0.62, 95%CI 0.48-0.79) but not in patients without additional high-risk features (67.1% vs. 53.2%; HR 0.83, 95%CI 0.55-1.24). CONCLUSIONS:Receipt of AC was associated with improved survival in patients with inadequate lymphadenectomy and any additional high-risk feature. Multiple variables may be considered in decisions regarding AC.