The role of primary tumour resection (PTR) in metastatic small intestinal (SiNETs) and pancreatic neuroendocrine tumours (PanNETs) remains debated. While retrospective studies suggest improved survival and possible reduction of local complications, the evidence is limited by heterogeneity, selection bias, and an absence of prospective validation. Under the auspices of the European Neuroendocrine Tumor Society (ENETS) Advisory Board, this position paper summarises current knowledge and expert consensus on the rationale, potential benefits, patient selection, timing, integration with systemic therapies, and future perspectives for PTR. PTR may be considered in selected patients with liver-limited or liver-dominant disease, indolent tumour biology, and good performance status, especially to prevent obstruction, bleeding, or ischaemia, to reduce symptomatic tumour burden, or to facilitate systemic and liver-directed therapies. However, the risks of major surgery, including intestinal and pancreatic resections, with long-term impact on digestion and nutrition, must be carefully considered. Decisions should be made in dedicated multidisciplinary tumour boards. Future directions include incorporation of molecular biomarkers, functional imaging, tumour growth rate, radiomics, and real-world data to refine patient selection. Quality of life and patient-reported outcomes remain underexplored and should be co-primary endpoints in prospective studies. PTR should not currently be regarded as standard of care for all cases but may have a role in carefully selected patients within integrated and individualised management strategies.

Pancreatic neuroendocrine tumors (PanNETs) are increasingly detected, and the optimal extent of resection remains uncertain because perioperative burden and oncologic assessment may differ by procedure. Enucleation (EN) and central pancreatectomy (CP) are often grouped together as parenchyma-sparing resections (PSRs) despite substantial differences in technical complexity, postoperative risk, and oncologic evaluation.We conducted a multicenter retrospective study of consecutive patients who underwent resection for pathologically confirmed PanNETs ≤20 mm. Procedures were categorized as EN, CP, pancreatoduodenectomy (PD), total pancreatectomy (TP), or distal pancreatectomy (DP). Primary outcomes were clinically relevant postoperative pancreatic fistula (CR-POPF) and major morbidity, defined as Clavien-Dindo grade ≥IIIa. A prespecified pairwise comparison focused on EN and CP, and pathologic assessment patterns were analyzed descriptively across procedures. Of 460 patients, 164 (35.7%) underwent EN, 40 (8.7%) CP, 84 (18.2%) PD/TP, and 172 (37.4%) DP. CR-POPF occurred in 115 patients (25.0%), major morbidity in 68 (14.8%), and 90-day mortality in 4 (0.9%). Among PSRs, CP had higher major morbidity than EN (25.0% vs 10.4%, p =.020), higher CR-POPF (50.0% vs. 24.4%, p =.003), and a longer median hospital stay (19.5 vs. 10.0 days, p <.001). Lymph node (LN) assessment was less frequent after EN than CP (40.4% vs. 87.5%, p <.001). Among assessed cases, LN metastases were identified in 44/320 patients (13.8%). EN and CP are not interchangeable as parenchyma-sparing options for small PanNETs. Among patients selected for resection, procedure selection should consider tumor location, function, technical feasibility, and oncologic requirements rather than size alone.

BACKGROUND:The absence of a standardized anatomical definition of the mesopancreas has precluded meaningful comparison across studies on total mesopancreas excision (TMpE). The MESODELPHI consensus aimed to establish international agreement on its definition, surgical boundaries, and clinical role in pancreatic cancer management. METHODS:An international modified Delphi process, informed by a prior systematic review, included 43 pancreatic surgery experts from 20 countries across two rounds. Statements were rated on a 5-point Likert scale, with consensus predefined as ≥80% agreement. RESULTS:Consensus was achieved for 19 of 27 statements in Round 1. All participants (100%) agreed the mesopancreas is a retropancreatic compartment of lymphatic, neurovascular, and adipose tissue, with 97.7% agreeing on its anatomical boundaries. Both artery-first and mesenteric-first approaches were considered feasible surgical strategies (97.7%). Most experts (81.4%) favored TMpE over conventional pancreatoduodenectomy for curative-intent surgery. There was strong agreement that further investigation into the impact of TMpE on survival outcomes is necessary (97.7%), and that education on mesopancreas anatomy should be integrated into surgical training programs (93.0%). CONCLUSIONS:This consensus provides the first standardized definition of the mesopancreas, recommends "mesopancreas" as the unifying term over alternative nomenclature, and offers an international framework to guide future research and surgical practice.

OBJECTIVE:To determine actual 5-year survival after neoadjuvant therapy and resection for pancreatic ductal adenocarcinoma (PDAC). BACKGROUND:Long-term outcomes after neoadjuvant therapy and resection for PDAC remain poorly defined, as current knowledge largely relies on actuarial estimates. METHODS:Retrospective cohort study of consecutive patients who underwent neoadjuvant therapy followed by curative-intent pancreatectomy for localized PDAC at 2 high-volume centers between January 2015 and February 2021. Only patients with complete follow-up (death or ≥5 y) were included. The primary endpoint was actual 5-year survival from surgery. RESULTS:Among 660 patients, actual 5-year survival was 34.5%. Recurrence occurred in 74.1% and was predominantly early, with nearly two-thirds of recurrences among patients who did not achieve 5-year survival occurring within 1 year after surgery. Long-term survivors had lower recurrence rates (92/228, 40.4%) and more commonly developed delayed (>2 y), locoregional, or pulmonary recurrence. The probability of achieving 5-year survival increased to 62.0% (95% CI: 56-67) and 81.9% (95% CI: 76-86) among patients who remained recurrence-free at 1 and 2 years, respectively. Actual 5-year survival was 42.5%, 29.0%, and 17.5% in patients with resectable, borderline-resectable, and locally advanced disease at diagnosis, respectively. Independent predictors of long-term survival included low comorbidity burden, baseline CA19-9 <200 U/mL, resectable disease at diagnosis, ypT0-1 stage, and R0 resection. CONCLUSIONS:Over one-third of patients undergoing neoadjuvant therapy and resection for localized PDAC were alive at 5 years, and most remained disease-free. Long-term outcomes were primarily determined by early systemic failure, whereas delayed oligometastatic recurrence identified a subgroup with prolonged survival.

OBJECTIVE:The International Study Group of Pancreatic Surgery (ISGPS) aimed to uniform the definition and classification of mortality following pancreatic resections, to guide strategies for reducing preventable deaths and standardize reporting. BACKGROUND:Reported rates of mortality after pancreatic surgery vary widely depending on patient comorbidities, case mix, and institutional expertise and resources. Conventional reporting lacks granularity and fails to capture the mechanisms leading to death. A standardized classification rooted in causal analysis may provide a more meaningful framework to appraise outcomes and design targeted interventions. METHODS:A systematic review of the literature, focusing on mortality rates, causes of death, and existing classification systems after pancreatectomy was conducted. A consensus definition and tripartite classification were developed through iterative discussions, revisions, and final approval by the ISGPS board members. RESULTS:Postpancreatectomy mortality (PPM) was defined as death occurring within 90 days of any pancreatic resection, directly or indirectly attributable to a surgical complication and retrospectively linked to it through root-cause analysis. Three categories were established: PPM 1, vascular/technical complexity-related mortality (15-30%); PPM 2, pancreatectomy-specific complication-related deaths, mainly due to postoperative pancreatic fistula (POPF) and secondary systemic deterioration (45-65%); and PPM 3, cardiopulmonary and cerebrovascular deaths (10-25%). Each category reflects distinct mechanisms, timing of onset, intervention windows, and opportunities for rescue. DISCUSSION:The proposed ISGPS classification of mortality enables the development of targeted strategies to reduce potentially preventable deaths and provides a more robust framework for the appraisal and benchmarking of surgical outcomes. Prospective validation is warranted to standardize this newly defined quality metric, ensuring its consistent use in future reporting and ultimately enhancing surgical quality and patient safety on a global scale.

Currently, no consensus exists regarding the definition of oligometastatic pancreatic ductal adenocarcinoma, its necessary diagnostic measures, and potential treatment approaches. To address these knowledge gaps, the OligoPanc project brought together an interdisciplinary group of experts to establish consensus using a modified Delphi process and clinical vignettes. Participants agreed that the number of metastatic lesions and the number of affected organs are key elements in defining oligometastatic pancreatic ductal adenocarcinoma. Specifically, up to three lesions in a single organ, either the liver or the lung, define oligometastatic pancreatic ductal adenocarcinoma and could be either synchronous or metachronous. Necessary diagnostics include a triple-phase contrast-enhanced CT scan of the chest and abdomen and MRI of the liver with a hepatocyte-specific contrast agent. In unclear cases, [18F]fluorodeoxyglucose-PET CT or MRI can be considered. A multidisciplinary tumour board is essential. Patient-intrinsic factors, including age, do not define oligometastatic disease but should be considered for any treatment decision. Systemic treatment before any local consolidative treatment, including surgery, stereotactic ablative radiotherapy, or other locally ablative techniques, is mandatory. The proposed definition should be incorporated into future trials to improve comparability and enable validation.

Graft pancreatitis is a clinically relevant but poorly standardized complication after pancreas transplantation (PT). In contrast, post-pancreatectomy acute pancreatitis has been formally defined and validated by the International Study Group for Pancreatic Surgery (ISGPS). This study assessed the clinical applicability of an adapted ISGPS-based framework to define post-transplant acute pancreatitis (PTAP) after PT and its association with clinically relevant outcomes. Consecutive patients undergoing PT at three European centers between 2010 and 2024 were included. PTAP was defined by sustained postoperative hyperamylasemia (POH) for ≥48 h combined with CT findings consistent with pancreatitis within 30 days after transplantation. Imaging was performed in 89% of patients based on clinical indication and center-specific protocols. Among 432 patients, the adapted definition was applicable in 416. Sustained POH occurred in 196 patients (47%), and PTAP was diagnosed in 86 (21%). PTAP was the only independent predictor of severe postoperative complications (OR, 2.482; P = 0.001), was independently associated with prolonged hospital stay (OR, 3.817; P < 0.001), and with worse death-censored graft survival (P < 0.001). Cold ischemia time was the only independent determinant of PTAP (P < 0.001). PTAP was a frequent and clinically meaningful complication after PT, occurring in approximately one in five patients and associated with worse short- and long-term outcomes.

Importance Total pancreatectomy (TP) is indicated for advanced pancreatic cancer or multifocal tumors. Furthermore, TP may be performed to avoid the risk of pancreatic fistula in selected patients to improve the perioperative risk profile. Objective To define reference values for TP based on a low-risk cohort treated at expert centers. Design, Setting, and Participants This multicenter study analyzed outcomes from patients undergoing primary TP for malignant or benign lesions from 25 international expert centers from January 2017 to November 2023. Low-risk patients undergoing TP (LR-TP) were without vascular resections or significant comorbidities. Exposures TP. Main Outcomes and Measures Twenty reference values were derived from the 75th or the 25th percentile of the median values of all centers. Outcomes of LR-TP were compared with a cohort of TP with vascular resection, TP due to high-risk pancreatic anastomosis, and the benchmark values for low-risk pancreatoduodenectomy. Results Of 994 patients, 333 (33.5%; median [IQR] age, 66 [58-72] years; 171 male [51.4%]) qualified as the LR-TP cohort. Reference values included blood loss (≤1000 mL), major complications (≤37%), 3-month postoperative mortality (<6%), and retrieved lymph nodes (≥29). Compared with TP with vascular resections, reference cutoffs were not met for major complications (51% vs LR-TP ≤37%) and 90-day mortality (11% vs LR-TP ≤6%). For TP due to high-risk anastomosis, failure to rescue rate (38% vs ≤6%) and 90-day mortality (11% vs LR-TP ≤6%) were not met. Compared with pancreatoduodenectomy, reference values for postoperative mortality were 3 times higher for LR-TP (≤2% vs ≤6%) and less for resected lymph nodes (≥16 vs ≥29). Conclusions and Relevance This case-control study provided global reference values for TP, indicating significantly higher postoperative morbidity and mortality compared with pancreatoduodenectomy. Perioperative morbidity of TP was especially increased in patients with vascular resections. These reference values can serve for quality control of pancreatic surgery.

Although surgical volume has a well-known association with outcomes in pancreatic surgery, volume alone does not necessarily guarantee quality for pancreatic ductal adenocarcinoma (PDAC). The study aimed to provide an overview of current surgical practices and short-term outcomes for PDAC in Italy. A retrospective multicentre study was conducted including all patients who underwent surgery for PDAC at 29 centers between 2018 and 2021. Centers were categorized by annual pancreatic surgical volume as low (1–10), medium (11–50), high (51–100), and very-high (> 100). The primary outcome was 90-day postoperative mortality. A total of 3455 patients were included, treated in low- (n = 26), medium- (n = 1103), high- (n = 322), and very-high-volume (n = 2004) centers. The median PDAC-surgeries per year was 27 (IQR 23–28) in high- and 107 (IQR 64–204) in very-high-volume centers. Preoperative histological diagnosis was obtained in 66.6

BACKGROUND:Following neoadjuvant treatment (NAT) and resection with radical intent, not all patients with pancreatic ductal adenocarcinoma (PDAC) seem to achieve a meaningful survival benefit, as some experience very-early recurrence and succumb shortly thereafter. This study aimed to identify preoperative risk factors of mortality within 1-year after NAT and surgery. PATIENTS AND METHODS:Retrospective analysis of all patients who underwent radical resection for PDAC after at least 3-months of NAT between January 2015 and March 2023. Early-death (ED) was defined as disease-related mortality within 12-months of surgery, excluding surgery-related mortality. Receiver operating characteristic (ROC) curve analysis was used to determine statistically derived thresholds for continuous variables. Multivariable logistic regression was conducted to identify factors associated with ED, which were subsequently evaluated in an external cohort. RESULTS:Overall, 418 patients were included. After a median follow-up of 37 months (95%CI 34-39), 44 patients (10.5%) experienced ED, with a median survival from diagnosis of 17 months (95%CI 15-18) and a disease-free survival of 4 months (95%CI 3-4). Radiological tumor size ≥ 25 mm (OR 3.81, 95%CI 1.84-7.91, p < 0.001) and CA19-9 ≥ 100 U/mL (OR 2.93, 95%CI 1.41-6.05, p = 0.004) were independently associated with ED. These associations were confirmed in the external cohort of 473 patients (OR 3.93, 95%CI 2.39-6.45, p < 0.001 and OR 1.81, 95%CI 1.08-3.03, p = 0.023, respectively). CONCLUSIONS:In this study, post-treatment CA19-9 ≥ 100 U/mL and tumor size ≥ 25 mm were associated with an increased risk of early-death after resection following NAT, representing warning signs in surgical decision-making and preoperative counselling.

The oncologically appropriate surgery for neck pancreatic ductal adenocarcinoma (PDAC) remains challenging due to the absence of standardized criteria. This study aims to preoperatively identify patients with neck PDAC at high risk of metastatic body-tail peripancreatic lymph nodes (BT-PLNs). This retrospective cohort study included adult patients undergoing resection for neck PDAC at San Raffaele Hospital (Milan, Italy). Patients with metastatic BT-PLNs were identified from histopathological records. Age, preoperative tumor size, preoperative Ca19.9, radiological response to neoadjuvant chemotherapy (NAT), resectability at diagnosis, and tumor site (distance in millimeters from the superior mesenteric vein and the point where the Wirsung duct starts dilating [W-SMV] on preoperative CT scan) were evaluated as potential predictors of metastatic BT-PLNs. Predictors were selected using multiple logistic regression with stepwise backward selection and then included in a predictive model to identify patients at high risk of metastatic BT-PLNs (online calculator: www.pancreaticneck.altervista.org ). A total of 143 patients were included (67 years [IQR 59–73], 60