AIMS:Accurate determination of tumour size is critical for pT staging in pancreatic ductal adenocarcinoma (PDAC), yet gross measurement alone often underestimates the true tumour extent because of the tumour's ill-defined and infiltrative nature. This study aimed to evaluate the diagnostic and prognostic value of incorporating microscopic rectification into tumour size assessment in PDAC. METHODS AND RESULTS:A total of 342 therapy-naïve pancreatoduodenectomies were analysed using a grossing protocol that includes separate sampling of anterior and posterior soft tissues via the 'orange-peeling' technique to retrieve lymph nodes and document soft tissue involvement. Peripancreatic soft tissue involvement was present in 91% of cases, and isolated microscopic foci distant from the main mass in 48%. Of the 266 tumours grossly classified as pT1/T2 (≤4 cm), 39 (14%) showed carcinoma in both anterior and posterior soft tissues, and were reclassified as pT3. This subset showed significantly worse survival (P = 0.04) and higher nodal positivity (87% versus 69%, P = 0.02) than the remaining pT2 cases, comparable to conventional pT3 tumours (86%, P = 0.77). Multivariable Cox regression adjusted for age, sex, nodal status, margin, and lymphovascular/perineural invasion confirmed the survival disadvantage of this subgroup. Reclassification yielded a more balanced distribution of T categories (pT2 66% → 52%, pT3 22% → 34%) and modestly improved prognostic discrimination (C-index: 0.592 versus 0.574). CONCLUSIONS:This study elucidates that PDAC frequently extends beyond the visible mass ('horses out of the barn' phenomenon); peripancreatic soft tissue involvement is common, and gross size often underestimates the true tumour extent, making microscopic correction crucial. Approximately one in six pT1/T2 tumours (≤4 cm) shows carcinoma in both anterior and posterior soft tissues and behave like pT3 in outcomes and nodal status. Therefore, gross-micro rectification is essential to avoid understaging, particularly for T2 tumours. The orange-peeling protocol should classify tumours with foci in both anterior and posterior soft tissues as pT3, while other approaches may employ mapping techniques to enable microscopic reconstruction and biologically accurate staging.

Multimodal therapy, combining chemotherapy and surgical resection, is the standard of care for patients with resectable pancreatic ductal adenocarcinoma (PDAC). Patients with poorly differentiated PDAC have suboptimal overall survival (OS), partly owing to the limited understanding of optimal timing for return to intended oncologic therapy (RIOT) after upfront surgery. We aim to evaluate patients with poorly differentiated PDAC who undergo upfront surgical resection and assess how the timing of receipt of adjuvant chemotherapy is associated with OS. Using the National Cancer Database, we identified patients with poorly differentiated nonmetastatic PDAC who received upfront surgical resection followed by adjuvant chemotherapy (2007–2016). Adjusted Cox proportional hazard models evaluated OS on the basis of RIOT timing. Logistic regression was used to identify factors associated with RIOT. Of 2737 included patients, 66.1

e16468 Background: Neoadjuvant chemo approach is favored in resectable/borderline resectable (R/BR) pancreatic ductal adenocarcinoma (PDAC) to increase the proportion of patients receiving systemic therapy. Current standard regimens, modified Folinic acid, Fluorouracil, Irinotecan, Oxaliplatin (mFOLFIRINOX) and gemcitabine nab-paclitaxel (GN), yield a 33% major pathologic response rate [SWOG S1505]. The regimen of capecitabine, cisplatin, nab-paclitaxel and gemcitabine (PAXG) improved median event free survival compared to mFOLFIRINOX but was equally toxic. The addition of cisplatin to GN(GCN) achieved a clinical response in 71% of patients with metastatic PDAC in a phase Ib/II trial. We evaluated the efficacy and safety of a biweekly neoadjuvant GCN regimen in R/BR PDAC patients. Methods: This ongoing single-arm phase II trial (NCT06423326) aims to evaluate biweekly neoadjuvant GCN in 36 patients with biopsy-proven R/BR PDAC (ECOG 0-1, no prior therapy, adequate organ function). GCN (G 800 mg/m², C 25 mg/m², N 100 mg/m²) is administered IV on days 1 and 15 of 28-day cycle for 4 cycles. CT scans were repeated every 2 weeks, and surgery occurred within 21-42 days after last chemo dose. The primary endpoint is clinical response including biochemical ( > 50% decrease in CA19-9), radiographic, pathologic responses or stable disease leading to surgical resection. Secondary endpoints include R0 resection rates, pathological response, chemotherapy completion, and recurrence free survival. Results: Between Aug 2024 and Dec 2025, 14 patients were enrolled and 12 were analyzed. The median age was 70.5 years; 50% males, 50% ECOG PS of 0 and 75% resectable disease. Median CA 19-9 was 192 (range 2–1542) before the first cycle and 67 (range 2–848) after the fourth cycle of GCN. Of 12 patients, 11 completed the 4 cycles and 4 (25%) required a dose reduction. 75% had biochemical response, all had stable radiographic disease (83%) or partial response (17%). 9 (75%) completed surgery, 89% of those had R0 resection and 33% node-negative. Any pathologic response was observed in 66% and 33% had a major pathologic response. Most resected patients completed adjuvant chemotherapy (8,89%) and 4/9 (45%) recurred. Grade 3 adverse events occurred in 75% (9/12), and included constipation (18%), neutropenia (18%), thromboembolic events (18%), anemia (9%), skin rash (9%), muscle pain (9%) and surgical wound infection (9%); no grade 3 neuropathy, grade 4 toxicities or treatment-related deaths occurred. Conclusions: Neoadjuvant biweekly gemcitabine, cisplatin and nab-paclitaxel is safe with favorable tolerability and manageable toxicity in patients with R/BR PDAC. The regimen demonstrates promising clinical response and high rates of surgical resection with the potential to outperform the current standard regimens, supporting the ongoing trial and further research. Clinical trial information: NCT06423326 .

Objective:The aim of this study was to evaluate the different phases of the learning curve for robotic distal pancreatectomy (RDP) in international expert centers.Background:RDP is an emerging minimally invasive approach; however, only limited, mostly single-center data are available on its safe implementation, including the learning curve.Methods:Consecutive patients undergoing elective RDP from 16 expert centers across 3 continents were included to assess the learning curve. Based on the first 100 RDPs at each center, 3 cutoffs were used to define the learning curve: operative time for competency, major complications (Clavien-Dindo grade >= III) for proficiency, and textbook outcome for mastery. Clinical outcomes before and after the cutoffs were compared.Results:The learning curve analysis was conducted on 1109 of 2403 RDPs. Competency, proficiency, and mastery, respectively, were reached after 46, 63, and 73 RDP procedures. After competency, operative time decreased from 245 to 235 minutes (P = 0.002). Attaining proficiency was reflected by a reduction in the rate of major complications from 20% to 15% (P = 0.012), and mastery was associated with a higher proportion of patients with textbook outcomes (71% vs 63%; P = 0.028). The postoperative pancreatic fistula rate remained stable along the learning curve, ranging between 18.5% and 21.5%. Previous laparoscopic experience accelerated the learning process by virtue of reduced operative time and an earlier decrease in major complications.Conclusions:Competency, proficiency, and mastery for RDP were reached after 46, 63, and 73 procedures, respectively, at international expert centers. The findings highlight that the learning curves for intraoperative parameters are completed earlier; however, extensive experience is needed to master RDP.

BACKGROUND:Despite improvements over time, Ivor Lewis Esophagectomy (ILE), a potentially curative surgical option for patients with invasive esophageal cancer, carries high morbidity and mortality. We analyzed postoperative outcomes in patients undergoing ILE at our institution, comparing open (OE), hybrid (HE), and totally minimally invasive (TMIE) approaches. METHODS:We reviewed the records of patients who underwent elective ILE for benign or malignant pathology at our institution (2018-2022). Patients who underwent transhiatal or McKeown esophagectomy, as well as those undergoing emergent procedures, were excluded. Factors associated with major postoperative complications (Clavien-Dindo Grade ≥ 3) were assessed using multivariable analysis (MVA). RESULTS:Of 260 patients, 135 met the inclusion criteria: 40 (29.6%) underwent OE, 50 (37.0%) underwent HE, and 45 (33.3%) underwent TMIE. Median length of stay was shorter for patients undergoing TMIE compared to OE and HE (9 vs. 12 and 13 days, p < 0.001). A higher major postoperative complication rate was noted in patients undergoing OE and HE compared to TMIE (32.5% and 36% vs. 13.3%) (p = 0.03). This result persisted on MVA (OE: aOR 3.4, p = 0.04; HE: aOR 5.5, p = 0.002; reference:TMIE). CONCLUSION:A totally minimally invasive approach to Ivor-Lewis Esophagectomy is associated with lower major postoperative complications and shortened length of stay at our institution. Prospective evaluations in the United States population are warranted to optimize and standardize surgical approaches.

Pancreatic ductal adenocarcinoma (PDAC) is a lethal malignancy with limited treatment options. Communicating risks and benefits in detail related to each treatment option as a part of the informed consent process is crucial to actively engage patients in their care process. Older age and emotional distress after diagnosis may impair cognitive impairment and compromise their autonomy in making an informed decision. Involvement of a multi-disciplinary team in the care process and supplementing various treatment option discussions with visual illustrations may help in simplifying complex information and improving patient understanding.

Objective: The aim of this study was to identify risk factors for conversion and assess its consequences on clinical outcomes after robotic distal pancreatectomy (RPD). Summary of Background Data: RDP has gained popularity due to its lower conversion rate (3–8%) when compared to laparoscopic distal pancreatectomy (10–20%). Methods: This retrospective multicenter study included RDPs performed at 16 international centers from May 2007 to March 2024. Perioperative outcomes of patients requiring conversion were compared to fully robotic RDP patients. Risk factors for conversion were identified by multivariable logistic regression analysis. Results: Of 2,452 patients undergoing RDP, 75 (3.1%) required conversion to open surgery. In converted RDPs, operative time was longer (300 (243–376) vs. 180 (120–240) minutes; P <0.001), and blood loss was greater (500 (200–990) vs. 100 (50–200) ml; P <0.001). Converted patients experienced more overall complications (53% vs. 39%; P =0.017), major complications (41% vs. 25%; P <0.001), and a higher 90-day mortality (5% vs. 3%; P <0.001). Furthermore, both postoperative pancreatic fistula (35% vs. 18%; P <0.001) and delayed gastric emptying (10% vs. 3%; P <0.001) were more frequent in the conversion group. The rate of patients achieving textbook outcome was lower after conversion (57% vs. 74%; P =0.003). In the multivariable analysis, lesion size (>51 mm; OR 2.86 (95% CI 1.56–5.08)), BMI (>28 kg/m 2 ; OR 3.03 (1.75–5.30)), previous abdominal surgery (OR 2.48 (1.31–4.51)), patients outside benchmark criteria (OR 2.09 (1.19–3.72)), and age (>62 years; OR 2.21 (1.24–4.05)) were associated with conversion. Conclusion: This international cohort study confirmed a very low conversion rate for RDP. Yet, converted cases experienced substantially impaired postoperative outcomes, highlighting the need for adequate patient selection through validated difficulty scoring systems.

Minimally invasive liver resection (MILR) is associated with fewer postoperative complications compared to open liver resection. Eastern Cooperative Oncology Group (ECOG) performance status (PS) is a fast, reproducible patient selection tool used to guide therapy. We compared patient outcomes after MILR by ECOG PS. Non-cirrhotic patients undergoing MILR resection at one of 14 North American healthcare centers were identified from the Americas Minimally Invasive Liver Surgery (AMILES) database (2010–2024). Perioperative outcomes were compared between ECOG1 and ECOG2 patients. Multivariable analysis (MVA) was used to identify factors independently associated with postoperative complications. Of 4,181 patients, 486 met our inclusion criteria. Median patient age was 62 years. Four-hundred twenty-eight patients (88.1

The pivotal role of Ki67 in grading pancreatic neuroendocrine tumors (PanNETs) is well recognized and firmly established in current WHO guidelines. Intratumoral heterogeneity is a well-known phenomenon, and it has also been documented for Ki67; however, the data on the magnitude of the impact of this heterogeneity on the final grade in primary NETs is relatively limited. In this study, Ki67 labeling index (KI) was calculated by using the manual count of camera-captured image method in 91 PanNETs both in hot-spots (KI(h)) as well as 6 different random-areas (KI(r)), each counted in a minimum of 2000 cells. The process was repeated for 29 samples from metastatic foci. Mean KI of the hot-spots was more than twofold higher than that of the random (5 vs 2.1

Objective: To establish the first consensus guidelines on the safety and indications of robotics in Hepato-Pancreatic-Biliary (HPB) surgery. The secondary aim was to identify priorities for future research. Background: HPB robotic surgery is reaching the IDEAL 2b exploration phase for innovative technology. An objective assessment endorsed by the HPB community is timely and needed. Methods: The ROBOT4HPB conference developed consensus guidelines using the Zurich-Danish model. An impartial and multidisciplinary jury produced unbiased guidelines based on the work of 10 expert panels answering predefined key questions and considering the best-quality evidence retrieved after a systematic review. The recommendations conformed with the GRADE and SIGN50 methodologies. Results: Sixty-four experts from 20 countries considered 285 studies, and the conference included an audience of 220 attendees. The jury (n=10) produced recommendations or statements covering 5 sections of robotic HPB surgery: technology, training and expertise, outcome assessment, and liver and pancreatic procedures. The recommendations supported the feasibility of robotics for most HPB procedures and its potential value in extending minimally invasive indications, emphasizing, however, the importance of expertise to ensure safety. The concept of expertise was defined broadly, encompassing requirements for credentialing HPB robotics at a given center. The jury prioritized relevant questions for future trials and emphasized the need for prospective registries, including validated outcome metrics for the forthcoming assessment of HPB robotics. Conclusions: The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.

BACKGROUND:Pancreaticoduodenectomy (PD) may occasionally be indicated for complete removal of periampullary (duodenal and ampullary) adenomas (PAs). As compared with malignant indications, PD for benign or premalignant disease is often associated with increased morbidity. Although the Spigelman classification assesses malignancy risk for familial adenomatous polyposis (FAP)-related duodenal adenomas, no malignancy risk score (MRS) exists for non-FAP-related PAs. We developed an MRS for non-FAP-related PAs undergoing PD to weigh the risk of malignancy and postoperative morbidity. STUDY DESIGN:We retrospectively analyzed patients with non-FAP-related PA who underwent PD at 8 institutions (2010 to 2022). Patient and lesion factors associated with final malignant pathology were identified using multivariable logistic regression to create MRS. Postoperative complications were assessed according to MRS. RESULTS:Of 127 patients, 59 (46.5%) had evidence of malignancy on final pathology. The odds of malignancy were higher in patients aged 65 years or older (odds ratio [OR] 3.2, p = 0.01), having bile duct 9 mm or more (OR 3.3, p = 0.009), having preoperative symptoms (OR 7.7, p = 0.002), and having high-grade dysplasia (OR 7.5, p < 0.001). A MRS was derived ranging from 0 to 6: age 65 years or older = 1, bile duct 9 mm or more = 1, symptomatic = 2, and high-grade dysplasia = 2. Patients were stratified into low-risk (MRS 1 to 2, n = 26), intermediate-risk (MRS 3 to 4, n = 59), and high-risk groups (MRS 5 to 6, n = 26), with malignancy rates increasing with MRS (10.3%, 44.1%, and 88.2%, p < 0.001). Patients in the no- or low-risk group (MRS 0 to 2) had higher odds of major postoperative complications compared with patients in the intermediate- or high-risk group (MRS 3 or higher, OR 2.9, p = 0.047). CONCLUSIONS:This novel MRS stratifies the risk of malignancy in non-FAP-related PAs managed with PD. This score can be used to counsel patients who may require PD for complete tumor removal about their risk of harboring malignancy and their risk of major postoperative complications.

ABSTRACTBackgroundOpioid crisis is a national issue with significant economic burden and marked increase in opioid‐related deaths, particularly following surgical procedures. Reducing opioid requirements while maintaining effective analgesia is critically challenging, perioperatively. Multimodal drug regimens and guided regional anesthesia (RA) have been adopted to address this issue. We aimed to assess postoperative opioid consumption in patients undergoing open pancreatoduodenectomy based on the routes of RA administration: open versus ultra‐sound guided.MethodsThis retrospective cohort study was conducted at Emory University Saint Joseph's Hospital, encompassing patients who underwent open pancreatoduodenectomy (PD) from 2020 to 2022 who received ultrasound‐guided RA (U‐RA) or open RA (O‐RA). Patient demographics, surgical details, and postoperative outcomes, including opioid consumption measured in morphine milligram equivalents (MME) at 24, 48, and 72 h, were analyzed. Multivariable linear regression identified predictors of postoperative opioid use.ResultsOf 95 patients, 47 met inclusion criteria: 27 received U‐RA and 20 O‐RA. Preoperative and intraoperative characteristics were similar between patients receiving O‐RA and U‐RA. A lower opioid requirement was noted in the O‐RA group compared to the U‐RA group at all time points. (24 h: 6.5 vs. 18, p = 0.004; 48 h: 18 vs. 37, p = 0.001; 72 h: 30.5 vs. 57, p = 0.002). On multivariable analysis, only route of regional anesthesia was independently associated with reduced opioid use across all time points (24 h: mean difference = −5.75, 95% CI: −11.3, −0.18; 48 h: mean difference = −16.95, 95% CI: −27.5, −6.4; 72 h: mean difference = −20.39, 95% CI: −35.4, −5.3) Patient age, gender, race, obesity, neoadjuvant chemotherapy, small pancreatic duct, and pancreatic fistula were not independently associated with opioid use.ConclusionsO‐RA may offer a better approach than U‐RA in minimizing opioid consumption after open PD. These findings suggest the incorporation of O‐RA for upper abdominal surgeries to decrease the necessity of postoperative opioids.

OBJECTIVE:The aim of this study was to identify risk factors for conversion and assess its consequences on clinical outcomes after robotic distal pancreatectomy (RPD). SUMMARY OF BACKGROUND DATA:RDP has gained popularity due to its lower conversion rate (3-8%) when compared to laparoscopic distal pancreatectomy (10-20%). METHODS:This retrospective multicenter study included RDPs performed at 16 international centers from May 2007 to March 2024. Perioperative outcomes of patients requiring conversion were compared to fully robotic RDP patients. Risk factors for conversion were identified by multivariable logistic regression analysis. RESULTS:Of 2,452 patients undergoing RDP, 75 (3.1%) required conversion to open surgery. In converted RDPs, operative time was longer (300 (243-376) vs. 180 (120-240) minutes; P<0.001), and blood loss was greater (500 (200-990) vs. 100 (50-200) ml; P<0.001). Converted patients experienced more overall complications (53% vs. 39%; P=0.017), major complications (41% vs. 25%; P<0.001), and a higher 90-day mortality (5% vs. 3%; P<0.001). Furthermore, both postoperative pancreatic fistula (35% vs. 18%; P<0.001) and delayed gastric emptying (10% vs. 3%; P<0.001) were more frequent in the conversion group. The rate of patients achieving textbook outcome was lower after conversion (57% vs. 74%; P=0.003). In the multivariable analysis, lesion size (>51 mm; OR 2.86 (95% CI 1.56-5.08)), BMI (>28 kg/m2; OR 3.03 (1.75-5.30)), previous abdominal surgery (OR 2.48 (1.31-4.51)), patients outside benchmark criteria (OR 2.09 (1.19-3.72)), and age (>62 years; OR 2.21 (1.24-4.05)) were associated with conversion. CONCLUSION:This international cohort study confirmed a very low conversion rate for RDP. Yet, converted cases experienced substantially impaired postoperative outcomes, highlighting the need for adequate patient selection through validated difficulty scoring systems.

BACKGROUND:Postoperative urinary retention warrants catheterization. A bladder scan helps check for postoperative urinary retention before catheterization. There is a paucity of data about its reliability in postoperative obese patients. Our study assesses its reliability in this patient population. METHODS:All patients in the postoperative ward of one hospital who underwent surgery during their current admission were included in our prospective cohort study. Patients were catheterized on the basis of the clinical judgment of the treating physician. The nurses collected bladder scan readings before catheterizing patients. Final analysis excluded patients with nongastrointestinal surgeries, record of fewer than 3 bladder scans readings, and missing urinary catheterized volume. The mean bladder scan readings (minimum = 3) were compared with the catheterized volume using intraclass correlation coefficient analysis. RESULTS:Of 100 patients, 65 met our selection criteria. Bladder scan reliability was good (intraclass correlation coefficient. 0.69; 95% confidence interval, 0.55-0.80) in the overall study cohort. A strong linear relationship was noted between bladder scan and catheterized volumes (r = 0.774, P < .001). Excellent reliability was noted in body mass index <30 subgroup (n = 43, intraclass correlation coefficient, 0.76, 95% confidence interval, 0.61-0.86), whereas the reliability was fair in body mass index ≥30 subgroup (n = 20, intraclass correlation coefficient, 0.55, 95% confidence interval, 0.26-0.81). Patients with body mass index ≥30 had a larger median difference between scan and catheterized volumes compared to patients with body mass index <30 (94.2 mL vs 34.8 mL). CONCLUSION:Our study demonstrates the accuracy and reliability of portable ultrasound bladder scans, especially in patients with healthy weight and overweight with postoperative urinary retention. The reliability may be suboptimal in obese patients.