INTRODUCTION:Pancreatic cancer surgery is highly complex and associated with significant perioperative risk, high mortality and morbidity, low quality of life, and increased healthcare costs. Establishing quality indicators to monitor these procedures may improve care quality and outcomes. This study aims to define a set of quality indicators to evaluate pancreatic cancer surgery in Catalonia. METHODS:A preliminary list of quality indicators was developed based on a literature review. Subsequently, a modified Delphi study was undertaken, involving 11 expert pancreatic surgeons, one from each center where these complex surgeries are authorized in Catalonia, to achieve consensus on quality indicators for pancreatic cancer surgery. RESULTS:The literature review yielded 21 potential quality indicators. After 4 rounds of voting, the expert panel accepted 17 indicators and rejected 4. The final set of quality indicators encompasses critical aspects including positive tumor resection margin, lymph nodes retrieved, postoperative complications, hospital readmission, reoperation, 90-day mortality and one-year survival. CONCLUSION:The outcome of this study is a set of agreed quality indicators to measure, describe and monitor the quality and outcomes of pancreatic cancer surgery. These quality indicators can be used as a foundation for benchmarking studies and systematic evaluations of quality of care and enhanced surgical performance in pancreatic cancer.

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

Minimally invasive pancreatoduodenectomy (PD), particularly through a robotic approach (RPD), is gaining increasing worldwide acceptance. However, high-quality evidence remains limited and very few randomized controlled trials have directly compared RPD with open PD (OPD). The SPAIN Trial (Spanish Pancreatoduodenectomy: Open vs. Robotic Approach) is designed to generate national evidence on the safety, efficacy, and economic value of RPD compared with the open technique. This is a national, multicentre, randomized, prospective, non-inferiority trial comparing RPD and OPD in high-volume Spanish centres with established robotic pancreatic programs. Adult patients indicated for elective PD due to benign or malignant disease of the pancreatic head, distal bile duct, duodenum, or ampulla of Vater will be randomized in a 2:1 ratio (2RPD:1OPD). The primary endpoint is overall postoperative morbidity within 90 days, assessed by the Comprehensive Complication Index (CCI). Secondary endpoints include intraoperative outcomes (operative time, blood loss, conversion rate), ISGPS-defined pancreatic complications, oncological outcomes (R0 resection, lymph node yield, time to adjuvant therapy), length of stay, readmission rates, and patient-reported quality of life using EQ-5D-5 L, EORTC QLQ-C30, and PAN-26 questionnaires. Cost-effectiveness will be assessed using Quality-Adjusted Life Years (QALYs) and Incremental Cost-Effectiveness Ratios (ICERs) from a healthcare perspective. Trial registration: ClinicalTrials.gov Identifier NCT06981273.

Postoperative pancreatic fistula (POPF) complicates 9.9–28.5

Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreatoduodenectomy, particularly in patients with high-risk pancreatic remnants. Preventive strategies based solely on surgical technique have yielded inconsistent results, and thus, there has been growing interest in strategies aiming to modify the biological behavior of the pancreatic remnant. This preclinical study evaluated the biological and histopathological effects of preoperative endoluminal radiofrequency ablation (ERFA) of the main pancreatic duct (MPD) performed 4 weeks before pancreatic transection in a porcine model. Animals underwent laparoscopic MPD occlusion followed by pancreatic transection at 4 weeks and necropsy 15 days thereafter. Feasibility, safety, histological atrophy, and macroscopic findings associated with POPF risk were assessed. As a secondary objective, outcomes were compared with those who underwent MPD occlusion using cyanoacrylate glue. Preoperative ERFA was technically feasible and safe. At 4 weeks, ERFA induced marked and homogeneous acinar atrophy that was significantly greater than that observed after glue occlusion (p = 0.018), indicating effective biological conditioning of the pancreatic remnant. At necropsy, pseudocyst formation and intra-abdominal adhesions, known surrogate markers of pancreatic fistula in pigs, were significantly more frequent in the glue group and absent in ERFA-treated animals. Serum amylase levels, postoperative weight gain, complication rates, and preservation of endocrine architecture were comparable between groups. Ductal ablation of the MPD via ERFA induced stable, progressive exocrine pancreatic atrophy, effectively preconditioning the gland prior to pancreatic transection. Experimental evidence suggests that its biological effects stabilize approximately 4 weeks after treatment. Compared to cyanoacrylate occlusion, ERFA achieved more homogeneous early biological effects and fewer fistula-related macroscopic complications. These findings support the further investigation of preoperative pancreatic conditioning as a potential adjunct strategy for POPF risk reduction, although clinical studies are needed to clarify its role alongside established reconstructive approaches.

BACKGROUND:Minimally invasive left pancreatectomy (MILP) has become the preferred approach to treat lesions of the pancreatic body and tail. However, the procedure may require conversion to open surgery, with reported conversion rates varying widely in the literature. This study aims to evaluate the incidence, causes, and clinical outcomes associated with conversion to open surgery in a prospective multicenter series. METHODS:The SPANDISPAN Project is a prospective, multicenter study conducted at 41 Spanish hospitals from February 2022 to January 2023. Patients were divided into conversion and nonconversion groups to identify predictors using univariate and multivariate logistic regression models. RESULTS:Of 313 recorded left pancreatectomies, 217 (69.3%) were MILP procedures. The conversion rate was 10.6%. Reasons for conversion included hemorrhage (60.9%) and intraoperative technical difficulties (39.1%). Multivariable analysis identified intraoperative blood loss (OR 1.65 per 100-mL increment; p < 0.001) and intraoperative transfusion (OR 7.777; p = 0.012) as independent intraoperative correlates of conversion, reflecting the bleeding-related process leading to conversion rather than preoperative predictors available for case selection. Low center volume was associated with a higher conversion rate in univariable analysis (14.5% vs. 6%; p = 0.042) with a nonsignificant protective trend for high-volume centers after multivariable adjustment (OR 0.339; p = 0.075). Although patients who required conversion had longer operative times and hospital stays, there were no significant differences in major complications, postoperative pancreatic fistula, or mortality between the groups. CONCLUSIONS:Conversion to open surgery during MILP is primarily driven by intraoperative bleeding-related events rather than by preoperative patient or tumor characteristics. Treatment at a high-volume center was associated with a lower conversion rate, although this trend did not reach significance after multivariable adjustment. Conversion was not associated with a significant increase in major morbidity or mortality in this cohort, supporting its use as a proactive safety measure rather than a surgical failure, although the limited number of conversion events warrants a cautious interpretation of this negative finding.

BackgroundAdenosquamous carcinoma of the pancreas (ASCP) is a rare and aggressive subtype of pancreatic cancer. Compared with other pancreatic tumors, ASCP has a notably poorer prognosis and shorter survival rates. The optimal therapeutic approaches to ASCP have yet to be defined.MethodsThis retrospective, multicenter European study included all consecutive patients who underwent elective pancreatic surgery for ASCP at participating centers between 2010 and 2024. The inclusion criteria encompassed all patients who underwent scheduled surgery for ASCP during the study period. The exclusion criteria ruled out patients without a confirmed pathologic diagnosis of ASCP, those who did not undergo surgery, and patients with extra-pancreatic disease.ResultsThe study analyzed 194 patients from 29 hospitals in 11 European countries. The overall survival rates were 56.2% at 1 year, 26.3% at 3 years, and 9.8% at 5 years. The disease-free survival rates at the same intervals were 36.6%, 16.5%, and 6.7%, respectively. In the multivariate analysis, significant associations with shorter survival were R2 resections, lymphatic stromal invasion, T4 stage, no adjuvant chemotherapy, and recurrence.ConclusionsPatients who undergo resection for ASCP experience very low 5-year survival rates (10%). It is advisable to avoid resecting T4 tumors in patients with significant comorbidities or R2 resections. Additionally, failure to provide adjuvant chemotherapy, often due to severe postoperative complications, further deteriorates the prognosis.

BACKGROUND:Spleen-preserving distal pancreatectomy by robotic surgery is a safe and feasible surgical technique. Currently, spleen-preserving distal pancreatectomy represents an alternative to the classical distal pancreatectomy with splenectomy, in the case of benign and low-grade malignant diseases of the body or pancreas tail. The reasons for preserving the spleen are based on the reduction of postoperative complications, such as post-splenectomy infections, subphrenic abscess, portal thrombosis, pulmonary hypertension, thrombocytosis, and thromboembolism. This procedure can be performed by completely preserving the splenic vessels (Kimura technique), not preserving the splenic vessels (Warshaw technique), or just resecting the splenic vein (Kim technique). RESULTS:The robotic approach is a feasible option for this surgery, in terms of reducing postoperative pain and facilitating patient recovery without increasing the risk of pancreatic fistula, hospital readmission, morbidity, and mortality. Compared with laparoscopy, robotic surgery demonstrates a lower conversion rate and reduced splenectomy rate. This surgical technique can be technically demanding, even robotically, therefore several maneuvers are described to reduce operative difficulty and improve surgical outcomes. CONCLUSIONS:The objective of this video is to provide a step-by-step guide to robotic spleen-preserving distal pancreatectomy surgery, highlighting tips and innovations for improved safety and effectiveness.

Minimally invasive liver surgery has become widely accepted as a safe and effective approach, especially with experienced surgeons. Robotic hepatectomy may offer significant benefits in challenging procedures like caudate lobe resection. The caudate lobe’s intricate anatomy and deep-seated location make its resection particularly challenging, with limited reports on minimally invasive techniques. The aim of this study was to assess the feasibility and safety of robotic isolated complete caudectomy and to provide a detailed description of the different technical approaches available. This retrospective multicenter study was conducted across eight experienced hepatobiliary robotic surgery centers between June 2020 and March 2024. All patients who underwent elective RICC during this period were included. Data were prospectively collected and retrospectively analyzed, focusing on demographics, intraoperative variables, postoperative outcomes, and histopathological results. The primary outcome was the feasibility and safety of the robotic approach. The study included 42 patients. The median (IQR) operative time was 180 (125–245) min, with a median estimated blood loss of 30 (0–100) ml. There were no conversions to open surgery and only one severe complication (Clavien-Dindo ≥ 3) occurred. No postoperative mortality was observed, and all resections for malignant lesions achieved R0 margins. The median time to flatus was 1 (1–1) day, time to solid diet was 1 (1–2) days, and the median length of stay was 3 (2–4) days. RICC is a feasible and safe procedure, demonstrating significant benefits in operative efficiency and patient recovery. However, further research with larger, prospective multicenter studies is necessary to confirm these findings and assess long-term outcomes.

Minimally invasive surgery (MIS) has transformed hepatobiliary procedures, providing significant advantages over traditional open techniques. However, challenges remain, especially in major hepatectomies and posterior segment resections due to the inherent limitations of laparoscopy. The caudate lobe (segment I), located deep within the liver and adjacent to critical vascular structures, presents unique technical difficulties, making it one of the most challenging segments to access laparoscopically. Robot-assisted surgery has emerged as a promising alternative, offering enhanced precision and control, allowing for more precise suturing and ligation of retrohepatic vessels and bile ducts. While there are still hurdles related to liver mobilization and hemostasis, these can be effectively managed through careful preoperative planning and intraoperative techniques, such as three-dimensional (3D) reconstructions and counterstaining with indocyanine green, which improve the safety and efficacy of anatomical caudate lobe resections. Therefore, this study aims to explore the safety and feasibility of robot-assisted complete caudectomy, detailing the technical aspects step-by-step through a case video example of an anatomical resection for hepatocarcinoma with Glissonean pedicle access.

INTRODUCTION:Surgical margins are crucial in determining postoperative local recurrence (LR) in patients with colorectal liver metastasis (CRLM) and hepatocellular carcinoma (HCC). Achieving a margin greater than 1 cm can be challenging due to constraints related to remnant liver reserve, proximity to major vascular structures and tumour depth. We previously published findings from a retrospective study suggesting that additional margin coagulation (AMC) using radiofrequency may reduce LR, and this multicentre randomised clinical trial aims to further assess this hypothesis. METHODS AND ANALYSIS:The LIVERATION trial is an international, multicentre, single-blind, randomised, parallel-group, controlled clinical trial involving 698 patients undergoing liver resection for CRLM or HCC. Participants will be randomly assigned in a 1:1 ratio to either AMC (study group) or conventional liver resection (control group) to assess oncological outcomes for both CRLM and HCC. The primary outcome is the incidence of LR. Secondary endpoints include overall survival, disease-free survival, cancer-specific survival, surgical complications and quality of life. Follow-ups occur at 30 days, 90 days, and 1, 2 and 3 years postoperatively. ETHICS AND DISSEMINATION:The LIVERATION trial has been approved by the Ethics Committee at the sponsor site Hospital del Mar de Barcelona, CEIM-PSMAR (Comité de Ética de la Investigación con Medicamentos - Parc de Salut Mar), as well as by the Institutional Ethics Committees in all participating countries. The results of the main trial, along with each of the secondary endpoints, will be submitted for publication in a peer-reviewed journal. The study adheres to national and international guidelines, including the Declaration of Helsinki, and complies with regulations for studies involving biological samples under Law 14/2007 on Biomedical Research. A dissemination strategy has been developed to engage stakeholders and facilitate knowledge transfer to support the use of the findings of the study. LIVERATION is funded by the European Union under the Horizon Europe Framework Programme (Project Number: 101104360). TRIAL REGISTRATION NUMBER:NCT05492136.