Benign stenosis frequently occurs after esophagectomy, causing dysphagia, eating problems, and diminished quality of life. This study aimed to identify risk factors for benign anastomotic stenosis after esophagectomy for cancer. This retrospective cohort study analyzed patients who underwent esophagectomy at Amsterdam UMC from 2012 until 2022. Intrathoracic and cervical anastomoses were examined separately. Benign anastomotic stenosis was defined as stenosis at the anastomosis causing dysphagia (Ogilvie score ≥2) and requiring at least one endoscopic dilation. Predictive factors were identified using logistic regression. The study enrolled 902 patients: 605 with intrathoracic and 297 with cervical anastomosis. Of these cases, 91.1

Background Preoperative endoscopic biliary drainage may lead to complications (16%-24%), potentially hampering surgical exploration. Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) may reduce drainage-related complications, however it is unknown whether EUS-CDS could in itself hamper surgical exploration as series with surgeon reported outcomes are lacking. Aim is to assess the impact of preoperative EUS-CDS on pancreatoduodenectomy. Method Consecutive patients who underwent pancreatoduodenectomy after preoperative biliary drainage were included in all eight centers that performed EUS-CDS in the mandatory Dutch Pancreatic Cancer Audit (Jan 2020-Dec 2022). Primary outcome was major postoperative complications. Secondary outcomes included bile leak grade B/C, postoperative pancreatic fistula (POPF) grade B/C, and overall postoperative complications. A propensity score matching (1:3) analysis was performed. Surgeons who performed a pancreatoduodenectomy after EUS-CDS were asked to complete a survey. Results Overall, 937 patients with pancreatoduodenectomy after preoperative biliary drainage were included (42 EUS-CDS, 895 ERCP). Major postoperative complications occurred in eight patients (19%) in the EUS-CDS group and 292 patients (33%) in the ERCP group (RR 0.50; 95%CI, 0.23-1.07). No significant differences were observed in overall complications (RR 0.95; 95%CI, 0.51-1.76), bile leak (RR 1.25; 95%CI, 0.31-4.98) or POPF (RR 0.62; 95%CI, 0.25-1.56). Results were similar after matching. The survey was completed for 29 pancreatoduodenectomies; surgery was not (n=13, 45%), ‘slightly’ (n=8, 28%), ‘clearly’ (n=5, 17%) or ‘severely’ (n=2, 7%) more complex because of the EUS-CDS. Conclusion This early experience suggests that preoperative biliary drainage with EUS-CDS does not increase the rate of complications after pancreatoduodenectomy and only infrequently hampers surgical exploration.

BACKGROUND:Prognostic factors in resected pancreatic ductal adenocarcinoma (PDAC) have been determined under the assumption that hazard ratios (HRs) remain static. However, PDAC is a dynamic disease with evolving conditional survival. The aim of this study was to determine if the impact of prognostic factors in PDAC is time-varying. METHODS:This was a multicenter, retrospective cohort study of the prospectively maintained Dutch Pancreatic Cancer Recurrence Database and New York University and Johns Hopkins Hospital Institutional Databases. Patients with complete macroscopic resection of histopathologically proven PDAC between 2014 and 2019 and available follow-up data were included. The time-varying impact of prognostic factors identified by univariable Cox regression was modeled using Aalen's Additive Regression Models (Aalen's models) and visualized as plots of cumulative hazard. RESULTS:In total, 3104 patients were included, of whom 938 (30.2%) received neoadjuvant therapy (NAT), whereas the rest underwent upfront surgery (US). A total of 201 (6.5%) patients achieved observed long-term survival (>5 years). Aalen's models showed that lymphovascular invasion, perineural invasion, and nodal disease were prognostic up to 2 years postoperatively. At varying points thereafter, these variables lost their impact in the NAT but not US patients. Similarly, during the fourth year of follow-up, American Society of Anesthesiology scores became impactful in the NAT but not in the US patients. CONCLUSION:The impact of prognostic factors in resected PDAC across NAT and US patients is time-varying. Our results suggest that aggressive disease drives early mortality but, after NAT, tumor-biological factors lose prognostic importance to frailty and comorbidities over time.

Abstract Background The introduction of (m)FOLFIRINOX and gemcitabine-nab-paclitaxel has changed the perspective for patients with locally advanced pancreatic cancer (LAPC). Consequently, in experienced centres 23% of patients with LAPC undergo a resection with 5-year overall survival (OS) rates of up to 25%. In the Netherlands, the nationwide resection rate for LAPC remains low at 8%. The PREOPANC-4 program aims for a nationwide implementation of the international multidisciplinary best-practice to improve patient outcome. Methods Nationwide program implementing the international multidisciplinary best-practice for LAPC. In the training phase, multidisciplinary and surgical webinars are given by 4 international experts, leading to a clinical protocol, followed by surgical off-site and on-site proctoring sessions. In the implementation phase, the clinical protocol will be implemented in all centres, including a nationwide expert panel (2022–2024). Healthcare professionals will be trained in shared decision-making. Consecutive patients diagnosed with pathology-proven LAPC (i.e., arterial involvement > 90° and/or portomesenteric venous > 270° involvement or occlusion [DPCG criteria]) are eligible. Primary outcomes are median and 5-year OS from diagnosis, resection rate, in-hospital/30-day mortality and major morbidity (i.e., Clavien-Dindo grade ≥ IIIa), and radical resection (R0) rate. Secondary outcomes include quality of life, functioning, side effects, and patients’ healthcare satisfaction in all included patients. Outcomes will be compared with patients with borderline resectable pancreatic cancer (BRPC) treated with neoadjuvant FOLFIRINOX in the PREOPANC-2 trial (EudraCT: 2017–002036-17) and a historical cohort of patients with LAPC from the PACAP registry (NCT03513705). The existing prospective LAPC Registry and PACAP PROMs (NCT03513705) will be used for data collection. In qualitative interviews, treatment preferences, values, and experiences of LAPC patients, their relatives, and healthcare professionals will be assessed for the development of shared decision-making supportive tools. It is hypothesized that the program will double the nationwide LAPC resection rate to 16% with major morbidity < 50% and mortality ≤ 5%, and OS following resection similar to that observed in patients with BRPC. Discussion The PREOPANC-4 program aims to safely implement the international multidisciplinary best-practice for LAPC leading to benchmark outcomes for both short-term morbidity, mortality, and OS. Trial registration PREOPANC-4 program was registered at ClinicalTrials.gov (NCT05524090) on September 1, 2022.

BACKGROUND:In patients with malignant gastric outlet obstruction, endoscopic ultrasonography-guided gastroenterostomy might be superior to surgical gastroenterostomy, but randomised trials are scarce. We aimed to assess time to resumption of oral intake and the rate of persistent or recurrent obstructive symptoms requiring re-intervention following endoscopic ultrasonography-guided gastroenterostomy compared with surgical gastroenterostomy. METHODS:ENDURO was a multicentre, randomised controlled trial conducted at 12 Dutch academic and teaching hospitals. Hospitals with experience in at least 20 LAMS placements of any indication, at least ten endoscopic gastroenterostomies, and approved competence were eligible to perform endoscopic gastroenterostomy independently within the trial. Adults aged 18 years and older with symptomatic, malignant gastric outlet obstruction in a palliative setting were randomly assigned (1:1) to endoscopic or surgical gastroenterostomy. Randomisation was performed with an electronic data capture system using randomly generated permuted blocks of 2 and 4 and stratified by WHO performance status (0-1 and 2-3). The first coprimary outcome was time to resumption of solid oral intake (Gastric Outlet Obstruction Scoring System score ≥2). The second coprimary outcome was non-inferiority for persistent or recurrent obstructive symptoms requiring re-intervention. The predefined non-inferiority margin of the risk difference was 20%. All outcomes were analysed in all randomly assigned participants. This trial was registered in the International Clinical Trials Registry Platform, NL9592, and is completed. FINDINGS:Between Feb 18, 2022, and Feb 26, 2024, 250 patients were screened, 98 of whom were randomly assigned to endoscopic gastroenterostomy (n=48) or surgical gastroenterostomy (n=50). 43 (44%) patients were female and 55 (56%) were male. Endoscopic gastroenterostomy had a shorter time to solid oral intake than surgical gastroenterostomy (median 1 day [IQR 1-3] vs 3 days [1-6], hazard ratio 2·21 [95% CI 1·43-3·42]; p=0·0003). Endoscopic gastroenterostomy was non-inferior to surgical gastroenterostomy for persistent or recurrent obstructive symptoms requiring re-intervention (five [10%] vs six [12%], risk difference 1·6% [upper limit of 90% CI 8·9]). Overall adverse events were reported in 28 (58%) patients in the endoscopic gastroenterostomy group and 32 (64%) in the surgical gastroenterostomy group (relative risk 0·91 [95% CI 0·66-1·25]). One fatal event occurred in the endoscopic gastroenterostomy group and three fatal events occurred in the surgical gastroenterostomy group. INTERPRETATION:In patients with malignant gastric outlet obstruction, palliative treatment with endoscopic gastroenterostomy was superior to surgical gastroenterostomy for time to resumption of solid oral intake and was non-inferior for the rate of persistent or recurrent obstructive symptoms requiring re-intervention. Based on these results, endoscopic gastroenterostomy should be the preferred palliative treatment for patients with malignant gastric outlet obstruction. FUNDING:KWF Dutch Cancer Society.

OBJECTIVE:To perform a cost analysis during the implementation of robot-assisted pancreatoduodenectomy (RPD) in a high-volume center. BACKGROUND:Many high-volume centers are implementing RPD as an alternative to open pancreatoduodenectomy (OPD) but the persevering concerns about increased costs of RPD versus OPD have not been addressed by large studies. METHODS:Post hoc cost analysis of consecutive RPD versus OPD in a singly high-volume center (January 2015-June 2024). The eligibility criteria for RPD (ie, no vascular contact, no chronic and necrotizing pancreatitis, and body mass index <35 kg/m 2 ) were used to select patients undergoing OPD to minimize selection bias. Primary outcomes were total hospital costs and total hospital stay. Sensitivity analyses excluded the first half of the RPD experience. RESULTS:Overall, 588 patients undergoing pancreatoduodenectomy were included (214 RPDs, 374 OPDs). Total hospital stay was shorter after RPD [10 days (6 to 17) vs 12 (8 to 21), P = 0.001]. Mean total hospital costs were €4804 higher for RPD (€27,307 vs €22,503, P = 0.010). Outcomes improved in the second half of the RPD experience (n = 107): total hospital stay [12 days (7 to 23) to 9 (6 to 15), P < 0.001], pancreatic fistula (48.6% to 31.8%, P = 0.012), delayed gastric emptying (33.6% to 15.0%, P = 0.001), and operative time [373 minutes (341 to 411) to 310 (272 to 352), P <0.001]. Consequently, costs per RPD procedure decreased by €11,058 (€32,836 to €21,778, P = 0.001). Costs in the second half of the OPD experience remained stable (€24,025 to €21,013, P = 0.210). Hence, total hospital costs for RPD and OPD became comparable in the second half (€21,778 vs €21,013, P = 0.644). CONCLUSIONS:Implementing RPD is associated with considerable additional costs compared with OPD. With growing experience, both the outcomes and cost-efficiency of RPD improve, with costs decreasing by approximately a third, leading to similar costs as OPD. Large-scale randomized trials will have to confirm these findings.

INTRODUCTION:Laparoscopic intestinal anastomosis requires specific technical skills and should be trained in a safe simulation environment before performing surgery in daily practice. However, anastomosis simulation training with objective feedback is not widely available. This study aimed to analyze a laparoscopic intestinal anastomosis training task that utilizes objective force, motion, and time measurements. METHODS:With the feedback of laparoscopic experts, an artificial tissue reproducible intestinal anastomosis training task was designed and developed. Novices and experts performed the training task four times using two running suture techniques, with a multifilament braided suture and a barbed suture. The laparoscopic box trainer (Lapron box trainer, Amsterdam Skills Centre, Amsterdam, the Netherlands) provided objective force, motion, and time feedback. The mean values of the parameters were calculated and analyzed using the Mann-Whitney U test. RESULTS:A total of 212 intestinal anastomosis repetitions were performed by 35 novices and 18 experts from 14 European teaching hospitals. For the multifilament braided sutures, experts showed significant lower maximal impulses (19.80 versus 12.90 Ns, P = 0.004), shorter total path length (23,545 mm versus 15,266 mm, P ≤ 0.001) and required less time to finish the task compared to novices (448 s versus 297 s, P ≤ 0.001). Using the barbed sutures, experts used significantly lower maximal forces (2.93 N versus 2.31 N, P = 0.032), had a shorter total path length (13,608 mm versus 8551 mm, P ≤ 0.001), and needed less time to execute the training task compared to novices (253 s versus 166 s, P ≤ 0.001). CONCLUSIONS:The development of a modular and reproducible laparoscopic intestinal anastomosis training task with established construct validity for force, motion, and time-based assessment of technical skills allows for repetitive training of advanced skills. These outcomes can now be utilized to assess translation of these skills into the operating room.

Objective: To investigate whether tangential versus segmental portomesenteric venous resection (PVR) impacts surgical and oncological outcome in patients undergoing pancreatoduodenectomy for pancreatic cancer with portomesenteric vein (PMV) involvement. Summary Background Data: Current comparative studies on tangential versus segmental PVR as part of pancreatoduodenectomy for pancreatic cancer include all degrees of PMV involvement, including cases where tangential PVR may not be a feasible approach, limiting the clinical applicability. Methods: International retrospective study in 10 centers from 5 countries, including all consecutive patients after pancreatoduodenectomy with PVR for pancreatic cancer with ≤180° PMV involvement on cross-sectional imaging at diagnosis (2014-2020). Cox and logistic regression analyses were performed to investigate the association of tangential versus segmental PVR with overall survival (OS) from surgery, recurrence-free survival (RFS), locoregional recurrence, and in-hospital/30-day major morbidity, adjusting for potential confounders. Results: Overall, 357 patients who underwent pancreatoduodenectomy with PVR were included (42% tangential PVR, 58% segmental PVR). The adjusted risk for in-hospital/30-day major morbidity was 23% (95%CI, 17-32) after tangential and 23% (95%CI, 17-30) after segmental PVR (P=0.98). After adjusting for confounders, PVR type was not associated with OS (HR=0.94 [95%CI, 0.69-1.30]), RFS (HR=0.94 [95% CI, 0.69 to 1.28), and locoregional recurrence (OR=0.76 [95%CI, 0.40-1.46]). Conclusions: In patients undergoing pancreatoduodenectomy for pancreatic cancer with ≤180° PMV involvement, the type of PVR (i.e., tangential vs. segmental) was not associated with differences in surgical and oncological outcome. This suggest that if both procedures are technically feasible, surgeons can choose the type of PVR based on their preference.

Preoperative anemia is an important target in preventing colorectal anastomotic leakage (CAL). However, it is not consistently detected and corrected in patients undergoing colorectal surgery. This study aimed to evaluate the impact of early detection and correction of preoperative anemia on perioperative outcomes and CAL. This was a prospective subanalysis of an international open-labeled trial, which implemented an enhanced care bundle to prevent CAL after elective colorectal surgeries. It introduced interventions for early detection and correction of preoperative anemia. Primary outcome was the incidence of preoperative anemia and the effect of early correction. Secondary outcomes included the impact on CAL, postoperative course, and mortality. The study included 899 patients across eight European hospitals (September 2021–December 2023). Preoperative anemia was identified in 35.0

INTRODUCTION:Colorectal resection carries a 2.8 %-30 % risk of anastomotic leakage. Machine learning can estimate risks and guide decisions, but clinical implementation remains inadequate due to transparency issues. This review assesses the performance and transparency of machine learning models compared to logistic regression. METHODS:A systematic review followed PRISMA guidelines. Medline, Embase, Web of Science, and Cochrane databases were searched for studies using Logistic Regression or Machine Learning with external validation for colorectal anastomotic leakage prediction. Data were extracted using CHARMS, risk of bias assessed with PROBAST, and transparency with TRIPOD + AI. RESULTS:Ten studies were included. Machine learning models were validated on smaller cohorts than logistic regression. Transparency scores ranged from 29 % to 63 %, averaging 45 % for logistic regression and 43 % for machine learning. Reporting of missing data was inconsistent, and external validation was limited. Most studies had a high risk of bias due to small sample sizes and low event counts. CONCLUSION:In comparison to Logistic regression studies, machine learning studies are limited by small cohorts, low outcome numbers, and a lower level of transparency. Future research should prioritise transparency, adhere to TRIPOD + AI standards, and develop LR and ML models in parallel using the same datasets while ensuring separate models for colon and rectal surgery. Currently, these models are not yet suitable for clinical implementation; more robust and transparent models must be developed based on these recommendations before they can be applied in clinical practice.

Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer-related deaths, with accurate staging being critical for treatment planning. Automated 3D segmentation models can aid in staging, but segmenting PDAC, especially in cases of locally advanced pancreatic cancer (LAPC), is challenging due to the tumor's heterogeneous appearance, irregular shapes, and extensive infiltration. This study developed and evaluated a tripartite self-supervised learning architecture for improved 3D segmentation of LAPC, addressing the challenges of heterogeneous appearance, irregular shapes, and extensive infiltration in PDAC. We implemented a tripartite architecture consisting of a teacher model, a professor model, and a student model. The teacher model, trained on manually segmented CT scans, generated initial pseudo-segmentations. The professor model refined these segmentations, which were then used to train the student model. We utilized 1115 CT scans from 903 patients for training. Three expert abdominal radiologists manually segmented 30 CT scans from 27 patients with LAPC, serving as reference standards. We evaluated the performance using DICE, Hausdorff distance (HD95), and mean surface distance (MSD). The teacher, professor, and student models achieved average DICE scores of 0.60, 0.73, and 0.75, respectively, with significant boundary accuracy improvements (teacher HD95/MSD, 25.71/5.96 mm; professor, 9.68/1.96 mm; student, 4.79/1.34 mm). Our findings demonstrate that the professor model significantly enhances segmentation accuracy for LAPC (p < 0.01). Both the professor and student models offer substantial improvements over previous work. The introduced tripartite self-supervised learning architecture shows promise for improving automated 3D segmentation of LAPC, potentially aiding in more accurate staging and treatment planning.

Background: Preoperative planning of patients diagnosed with pancreatic head cancer is difficult and requires specific expertise. This pilot study assesses the added value of three-dimensional (3D) patient models and computer-aided detection (CAD) algorithms in determining the resectability of pancreatic head tumors. Methods: This study included 14 hepatopancreatobiliary experts from eight hospitals. The participants assessed three radiologically resectable and three radiologically borderline resectable cases in a simulated setting via crossover design. Groups were divided in controls (using a CT scan), a 3D group (using a CT scan and 3D models), and a CAD group (using a CT scan, 3D and CAD). For the perceived fulfillment of preoperative needs, the quality and confidence of clinical decision-making were evaluated. Results: A higher perceived ability to determine degrees and the length of tumor–vessel contact was reported in the CAD group compared to controls (p = 0.022 and p = 0.003, respectively). Lower degrees of tumor–vessel contact were predicted for radiologically borderline resectable tumors in the CAD group compared to controls (p = 0.037). Higher confidence levels were observed in predicting the need for vascular resection in the 3D group compared to controls (p = 0.033) for all cases combined. Conclusions: “CAD (including 3D) improved experts’ perceived ability to accurately assess vessel involvement and supports the development of evolving techniques that may enhance the diagnosis and treatment of pancreatic cancer”.

BackgroundTechnological innovations have significantly enhanced the objective assessment of technical skills in minimally invasive surgery, offering substantial potential for proficiency-based training. However, the integration of these innovative tools into surgical education curricula remains limited. This study aims to evaluate the adoption and implementation of data-driven assessment tools within laparoscopic simulation training.MethodsA systematic search of PubMed and Embase was conducted following PRISMA guidelines, identifying studies that employed objective assessments of technical skills in surgical training curricula. Eligible studies utilized data-driven assessment methods as part of structured training programs for surgical residents. A descriptive analysis was performed on the included studies.ResultsFrom 2814 identified articles, 718 were eligible for full-text screening, and 35 studies met the inclusion criteria. These studies described the implementation of 14 different data-driven tools in laparoscopic skills training. Most tools focused on assessing instrument handling, measuring parameters such as motion speed, path length, and accuracy. Only three studies evaluated tissue handling skills using metrics like knot quality, tissue handling forces, and anastomotic integrity.ConclusionsThe adoption of data-driven tools in laparoscopic simulation training is progressing slowly and exhibits considerable variability. Most technologies emphasize instrument handling, while tools for assessing tissue manipulation and force application are limited. To improve training outcomes, a combination of motion- and force-based assessment tools should be considered, enabling a more comprehensive evaluation of technical skills in minimally invasive surgery.

OBJECTIVE:To identify strategies to prevent and treat delayed gastric emptying (DGE) after pancreatic surgery. BACKGROUND:Among all complications of pancreatic surgery, DGE has the largest impact on prolonged hospital stays. Several randomized controlled trials (RCTs) have addressed DGE after pancreatic surgery, either as primary or as secondary outcome. METHODS:RCTs involving pancreatic surgery with DGE as primary or secondary outcome were identified using the online database of the ISGPS Evidence Map of Pancreatic Surgery (2007-2023). Meta-analysis was performed for impact on DGE grade B/C for interventions studied by at least 2 RCTs. RESULTS:Overall, 152 RCTs were included with 22,260 patients undergoing pancreatic surgery. The overall rate of DGE grade B/C was 11.9%, including 12.7% after pancreatoduodenectomy and 4.2% after left pancreatectomy. No RCT identified an effective treatment of DGE grade B/C. Strategies that reduced the rate of DGE in at least one RCT included: prehabilitation, pancreatico-jejunostomy, antecolic gastrojejunostomy, Billroth II technique, pylorus resection, modified Roux-en-Y technique, no intraperitoneal drainage in left pancreatectomy, minimally invasive left pancreatectomy, minimally invasive pancreatoduodenectomy, mERAS, nasojejunal tube, and early oral feeding. Additional meta-analyses identified minimally-invasive left pancreatectomy as preventive for DGE grade B/C compared with open left pancreatectomy. CONCLUSIONS:This systematic review of RCTs identified 12 strategies that reduced the rate of DGE grade B/C after pancreatic surgery but no effective treatment strategy. Of the 12 preventive strategies, only minimally invasive left pancreatectomy was confirmed effective in a meta-analysis. Future RCTs should focus on both the prevention and treatment of DGE after pancreatic surgery.

OBJECTIVE:To investigate whether tangential versus segmental portomesenteric venous resection (PVR) impacts surgical and oncological outcome in patients undergoing pancreatoduodenectomy for pancreatic cancer with portomesenteric vein (PMV) involvement. SUMMARY BACKGROUND DATA:Current comparative studies on tangential versus segmental PVR as part of pancreatoduodenectomy for pancreatic cancer include all degrees of PMV involvement, including cases where tangential PVR may not be a feasible approach, limiting the clinical applicability. METHODS:International retrospective study in 10 centers from 5 countries, including all consecutive patients after pancreatoduodenectomy with PVR for pancreatic cancer with ≤180° PMV involvement on cross-sectional imaging at diagnosis (2014-2020). Cox and logistic regression analyses were performed to investigate the association of tangential versus segmental PVR with overall survival (OS) from surgery, recurrence-free survival (RFS), locoregional recurrence, and in-hospital/30-day major morbidity, adjusting for potential confounders. RESULTS:Overall, 357 patients who underwent pancreatoduodenectomy with PVR were included (42% tangential PVR, 58% segmental PVR). The adjusted risk for in-hospital/30-day major morbidity was 23% (95%CI, 17-32) after tangential and 23% (95%CI, 17-30) after segmental PVR (P=0.98). After adjusting for confounders, PVR type was not associated with OS (HR=0.94 [95%CI, 0.69-1.30]), RFS (HR=0.94 [95% CI, 0.69 to 1.28), and locoregional recurrence (OR=0.76 [95%CI, 0.40-1.46]). CONCLUSIONS:In patients undergoing pancreatoduodenectomy for pancreatic cancer with ≤180° PMV involvement, the type of PVR (i.e., tangential vs. segmental) was not associated with differences in surgical and oncological outcome. This suggest that if both procedures are technically feasible, surgeons can choose the type of PVR based on their preference.

BACKGROUND:Preoperative endoscopic biliary drainage may lead to complications (16 %-24 %), potentially hampering surgical exploration. Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) may reduce drainage-related complications; however, in the absence of surgeon-reported outcomes, it is unknown whether EUS-CDS may hamper surgical exploration. This study assessed the impact of preoperative EUS-CDS on pancreatoduodenectomy. METHOD:Consecutive patients who underwent pancreatoduodenectomy after preoperative biliary drainage were included in all eight centers performing EUS-CDS in the mandatory Dutch Pancreatic Cancer Audit (Jan 2020-Dec 2022). The primary outcome was major postoperative complications. Secondary outcomes included bile leak grade B/C, postoperative pancreatic fistula (POPF) grade B/C, and overall postoperative complications. A propensity score-matching (1:3) analysis was performed. Surgeons performing pancreatoduodenectomy after EUS-CDS completed a survey on surgical difficulty. RESULTS:937 patients with pancreatoduodenectomy after preoperative biliary drainage were included (42 EUS-CDS, 895 endoscopic retrograde cholangiopancreatography [ERCP]). Major postoperative complications occurred in 8 patients (19.0 %) in the EUS-CDS group and 292 (32.6 %) in the ERCP group (relative risk [RR] 0.50; 95 %CI 0.23-1.07). No significant differences were observed in overall complications (RR 0.95; 95 %CI 0.51-1.76), bile leak (RR 1.25; 95 %CI 0.31-4.98), or POPF (RR 0.62; 95 %CI 0.25-1.56). Results were similar after matching. The survey was completed for 29 pancreatoduodenectomies; surgery was not (13, 45 %), "slightly" (9, 31 %), "clearly" (5,17 %), and "severely" (2, 7 %) more complex because of EUS-CDS. CONCLUSION:This early experience suggests that preoperative biliary drainage with EUS-CDS does not increase the rate of complications after pancreatoduodenectomy and only infrequently hampers surgical exploration.