BACKGROUND:The role of checking the pancreatic neck margin with frozen section (PNM-FS) during pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) to secure R0 resection and its impact on long-term outcomes remains an area of debate. PATIENTS AND METHODS:Patients with PD for PDAC between 2018 and 2023 were included. The primary outcome was pancreatic neck recurrence-free survival (PN-RFS). Secondary outcomes were locoregional recurrence-free survival (LR-RFS), distant recurrence-free survival (D-RFS), and overall survival (OS). RESULTS:There were 403 patients who met inclusion criteria. PNM-FS was checked in 361 patients (89.6.2%) and returned negative at first attempt in 285 (78.9%). A total of 76 patients had positive PNM-FS; 71 were revised and clearance achieved on repeat sampling in 49 (69.0%). Median PN-RFS in patients with PNM-FS cleared with revision was significantly shorter compared with those with negative PNM-FS at first attempt (16.9 versus 23.1 months; p = 0.048) but was not different from patients with PNM-FS not cleared (16.9 versus 16.0 months; p = 0.961). LR-RFS and D-RFS were not different between the groups. OS was marginally longer in patients with negative PNM-FS at first attempt (23.9 versus 19.4 versus 16.0 months; p = 0.049). Six patients underwent completion total pancreatectomy (TP) for margin clearance, four developed distant recurrence, one locoregional recurrence and two died without disease at 1 and 11 months postoperatively. CONCLUSIONS:PNM-FS is only a prognostic marker. Pursuing PNM-FS clearance does not improve PN-RFS, LR-RFS, D-RFS, or OS. Furthermore, pursuing a completion TP may be associated with shorter OS either from disease progression or surgical morbidity.

Background Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to increase survival in select patients with peritoneal metastasis. One point of contention is whether a cholecystectomy should be performed during the index CRS/HIPEC as this may avoid the risk of missing difficult-to-assess gallbladder (GB) tumor involvement and the potential for a higher-risk cholecystectomy in a post-CRS/HIPEC abdomen. We aim to evaluate the practice of cholecystectomy during CRS/HIPEC and analyze the outcomes of concurrent cholecystectomy. Methods Adult patients who underwent CRS with HIPEC across our quaternary care health center were retrospectively reviewed for GB disease pre- or post-CRS/HIPEC or GB intervention at index or post-CRS/HIPEC. Patients with prior cholecystectomy were excluded. Pre-operative variables collected included patient demographics, cancer diagnosis, and surgical history. Operative reports were reviewed for intraoperative GB evaluation, GB interventions, peritoneal cancer index (PCI), and surgeon specialty. Post-CRS/HIPEC GB disease, GB intervention, and associated complications, and mortality were collected. Cholecystectomy pathology reports were reviewed for GB disease and malignant involvement. Results Between 2009 and 2023, a total of 83 patients underwent CRS with HIPEC and met our inclusion criteria (Table 1). 64 patients underwent cholecystectomy at index CRS/HIPEC, with one Clavien-Dindo (CD) grade-I complication. Post-CRS/HIPEC GB intervention was required for 11 out of the 19 remaining patients (58%) which included 8 open cholecystectomies, 1 cholecystostomy tube, and 1 medical-management with 1 CD-IV complication during cholecystectomy. Two of the patients who required open cholecystectomy had preoperative evidence of cholelithiasis. Among the 64 patients who underwent concurrent cholecystectomy and CRS/HIPEC, 28 patients had evidence of malignant gallbladder involvement. Only 12 out of 20 patients with preoperative evidence of gall bladder disease underwent cholecystectomy at time of CRS/HIPEC. Cholelithiasis was the most common preoperative gall bladder disease. The concordance between intra-operative surgeon perspective of GB disease and final pathology was 56%. Patients who underwent cholecystectomy had a lower PCI compared to those who didn’t (p-value 0.014). Conclusion In our study, cholecystectomy performed during CRS/HIPEC has demonstrated minimal complications. Furthermore, cholecystectomy at time of CRS/HIPEC may ensure a more comprehensive removal of cancerous tissue. Cholecystectomy at the time of CRS/HIPEC may decrease the need for further interventions in this complex patient population.

OBJECTIVE:Characterize the additive value of endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) when applying specific surgical thresholds for pancreatic cystic neoplasms (PCNs). SUMMARY BACKGROUND DATA:When characterizing PCNs, MRI assesses lesion morphology, while EUS can confirm morphology and assess malignant risk through cyst fluid aspiration. Currently there is limited understanding of the additive benefit of sequential testing. METHODS:An institutional registry was queried for patients with an MRI and EUS for a PCN. Morphologic high-risk features (MHRF): mural nodule, pancreatic duct dilation, and thickened/enhanced wall were assessed on both modalities. Clinical courses were assessed for development of high-grade dysplasia/cancer on surgical pathology or surveillance. Diagnostic accuracy was established on surgical pathology. Receiver operating curves and decision-curve analysis were conducted to qualify the benefit afforded by each modality. RESULTS:Of 3702 registry patients, 1674 met inclusion criteria. MRI detected MHRF in 462 (28%) and EUS in 400 (24%), with discordance in 436 (26%). Morphologically negative MRI and EUS yielded a +FNA in 5%. MHRF on EUS but not MRI occurred in 187, with a confirmed upgrade rate of 66%. MHRF on MRI but not EUS occurred in 249, with 92% remaining cancer-free on surveillance [median: 49 (23-78) months]. In 215 surgical patients, EUS following normal MRI improved specificity by 14%, with MRI+EUS+FNA improving specificity to 38%. MRI+EUS+FNA demonstrated superior AUC versus MRI ( P =0.022). Decision-curve analysis demonstrated EUS provides greatest clinical benefit in MRIs without MHRF when combined with FNA. CONCLUSIONS:EUS and FNA provide a considerable contribution to clinical decision-making in MRIs without MHRF. STUDY DESIGN:Retrospective registry cohort study.

Chronic pancreatitis is a progressive inflammatory disorder marked by irreversible parenchymal injury, fibrosis, and multifactorial pain. Therapeutic endoscopy plays a central role in managing obstructive phenotypes and selected complications. This review synthesizes contemporary evidence on endoscopic management of pancreatic duct stones, main pancreatic duct strictures, benign biliary strictures (BBS), pancreatic duct leaks, pancreatic pseudocysts, and endoscopic ultrasound–guided celiac plexus block, addressing the role of endoscopy. A narrative review was performed, evaluating pain relief, ductal decompression, quality of life, adverse events, and reintervention across ERCP-based therapies, extracorporeal shock wave lithotripsy, pancreatoscopy-guided electrohydraulic or laser lithotripsy, and endoscopic management of pancreatic fluid collections and ductal leaks, and endoscopic ultrasound-guided pain interventions. In painful obstructive chronic pancreatitis, targeted endotherapy can provide symptom relief; however, randomized trials generally favor surgery drainage procedures and/or pancreatic resection over endoscopy for sustained pain control, ductal decompression, and physical quality of life, with comparable safety. ERCP alone is appropriate for small pancreatic duct stones, whereas larger stones are managed with extracorporeal shock wave lithotripsy or pancreatoscopy-guided electrohydraulic or laser lithotripsy to achieve ductal clearance. Main PD strictures are managed with dilation and stenting, with single large-caliber plastic stents preferred; routine use of fully covered self-expandable metal stents is discouraged due to higher adverse events. For chronic pancreatitis-associated BBS, fully covered metal and multiple plastic stents demonstrate similar long-term efficacy, with metal stents reducing procedural burden. Symptomatic PPCs are optimally managed endoscopically based on anatomy and ductal communication. EUS-CPB provides short-term analgesia for refractory pain. Endoscopic therapy is integral to multidisciplinary CP management, offering effective, anatomy-driven interventions, while surgery remains preferred for durable pain control in selected patients.

OBJECTIVE To evaluate ChatGPT's effectiveness in medical imaging interpretation within urology, addressing the critical need for safe AI application in healthcare by identifying its strengths and limitations as a diagnostic and educational resource. MATERIAL AND METHODS Using publicly available cases from Radiopaedia.com, we entered 1-3 CT or MRI images into ChatGPT. A standard prompt instructed the model to provide a differential diagnosis ranked by probability. This task was repeated a second time with organ guidance (OG), which provided the organ of diagnostic interest to the model (eg, kidney). Primary outcomes included whether the model's top or differential diagnosis correctly identified the underlying pathology. RESULTS ChatGPT correctly identified the pathologic condition as its top diagnosis in 14% of CT (7/50) and 28% (14/50) of MRI cases (P = .08). OG increased the model's ability to recognize the top diagnosis by 18% (P = .03) when interpreting CT images, a benefit not shared when interpreting MRI images (P = .4). At baseline the differential diagnosis contained the final diagnosis for 30% and 56% of CT and MRI cases (P = .03). With the inclusion of OG, the model's differential diagnosis was able to correctly identify the underlying condition in 62% of both CT and MRI cases (CT: P = .001, MRI: P = .31). CONCLUSION ChatGPT's effectiveness in medical imaging diagnostics is initially limited, yet it substantially benefits from the addition of user guidance. The study underscores AI's current shortcomings but also its considerable capacity to improve clinical operations when enriched with more data and expert direction. UROLOGY 196: 27-31, 2025. (c) 2025 The Authors. Published by Elsevier Inc.

BACKGROUND:Intraductal papillary mucinous neoplasms are cystic neoplasms of the pancreas with a risk of malignant transformation. They are categorized based on morphology and ductal involvement. Compared with side-branch intraductal papillary mucinous neoplasms, main duct intraductal papillary mucinous neoplasms and mixed-type intraductal papillary mucinous neoplasms are generally considered high risk. Radiologic main pancreatic duct dilatation is a recognized risk factor for high-grade dysplasia and/or invasive carcinoma. Studies thus far have not explored the association between radiologic main pancreatic duct dilatation and dysplasia of the main pancreatic duct epithelium on surgical pathology. METHODS:An institutional database of intraductal papillary mucinous neoplasms was queried for patients from 1997 to 2023 undergoing resection of a main duct or mixed-type intraductal papillary mucinous neoplasm with radiologic diagnosis of main pancreatic duct dilatation before surgery. The χ2 test, t test, logistic regression modeling, and Youden's index analysis were performed to test the association between "true" main pancreatic duct dysplasia involvement in surgical pathology reports and main pancreatic duct dilatation, as well as high-risk pathology (high-grade dysplasia or invasive carcinoma). RESULTS:A total of 91 patients were included in the final analysis. Radiologic main duct intraductal papillary mucinous neoplasms were more likely to demonstrate "true" main duct involvement versus mixed-type intraductal papillary mucinous neoplasms (79% vs 41%, P = .001). Among intraductal papillary mucinous neoplasms with true main pancreatic duct dysplasia, main duct intraductal papillary mucinous neoplasms were more likely than mixed-type intraductal papillary mucinous neoplasms to demonstrate invasive carcinoma on surgical pathology (27% vs 10%, P = .047). Cyst size was not predictive of main pancreatic duct dysplasia for mixed-type intraductal papillary mucinous neoplasms. Main pancreatic duct >9 mm at diagnosis was associated with increased likelihood of true main pancreatic duct dysplasia (odds ratio = 3.33, 95% confidence interval = 1.16-9.61 P = .026). Youden's index analysis demonstrated that a main pancreatic duct cutoff of 8.5 mm provided the greatest capability to predict main pancreatic duct dysplasia. CONCLUSION:Mixed-type intraductal papillary mucinous neoplasm confers less dysplasia risk in the main pancreatic duct, supporting maintaining the distinction of mixed-type and main duct intraductal papillary mucinous neoplasm due to potentially different management. This study reaffirms the use of main pancreatic duct dilatation in intraductal papillary mucinous neoplasm risk stratification, because main pancreatic duct dilatation >8 mm was predictive of main pancreatic duct epithelial dysplasia and high-risk pathology.

BACKGROUND:Side-branch intraductal papillary mucinous neoplasms (SB-IPMNs) are increasingly recognized with the increasing use of high-fidelity cross-sectional imaging, particularly subcentimeter (<1 cm) lesions. Data regarding the risk of progression in subcentimeter cysts are absent. This study aimed to define the risk associated with subcentimeter SB-IPMNs and to propose a surveillance strategy based on this cohort. METHODS:A prospectively maintained database was queried for patients with SB-IPMN who underwent nonoperative surveillance with ≥2 cross-sectional imaging studies performed >6 months apart. Clinically relevant (CR) progression has been previously defined as the development of symptoms, worrisome/high-risk stigmata, or invasive cancer (IC). Growth of ≥5 mm in 2 years is considered CR progression, whereas size of ≥3 cm alone is not. RESULTS:A total of 1000 patients were included in the study, of whom 291 (29.1%) had SB-IPMN of <1 cm. The median follow-up times from diagnosis were 7.1 years (IQR, 3.2-10.4) in subcentimeter cysts and 6.4 years (IQR, 2.8-10.0) in cysts of ≥1 cm (P =.090). CR progression was less common in the subcentimeter cyst group than in the larger cyst group (7.2% vs 19.0%, respectively; log-rank P <.001). Cysts that progressed did so at similar time intervals (median: 3.7 years in the subcentimeter cyst group vs 3.3 years in the larger cyst group; P =.707). The subcentimeter cyst group developed IC (1.4% in the subcentimeter cyst group vs 1.8% in the larger cyst group; log-rank; P =.608) and high-risk pathology (high-grade dysplasia [HGD]/IC) at a similar rate as the larger cyst group (P =.198). Of 547 patients with cysts that were initially stable for 5 years of surveillance, 25 (4.7%) developed high-risk pathology. This was not different by initial cyst size (log-rank P =.116). Spline curves demonstrated consistently low risk of HGD/IC across increasing cyst size despite a higher rate of CR progression. The CR progression criteria best discriminated high-risk pathology in subcentimeter cysts. The rate of size growth did not correlate with high-risk pathology (hazards ratio, 1.14; 95% CI, 0.88-1.50). CONCLUSION:Subcentimeter SB-IPMNs develop malignant potential as frequently as their larger counterparts and do so at similar time courses. Often incidental, subcentimeter-presumed SB-IPMNs are diagnosed at arbitrary points in the disease course and require similar surveillance duration as their larger counterparts. The rate of growth is not predictive of high-risk pathology. These cysts do not develop CR progression as frequently. However, such features better discriminate high-risk pathology in subcentimeter cysts, making the development of such features more concerning when they occur.

INTRODUCTION:Clinical practice guidelines for intraductal papillary mucinous neoplasms are based on expert opinion because of paucity of clinical evidence. We aim to establish the data-driven correlation between worrisome/high-risk/clinically relevant progression features and high-risk pathology on fine needle aspiration or resection. DESIGN:A prospectively maintained database (1997-2023) of presumed pancreatic cystic neoplasms was queried for intraductal papillary mucinous neoplasm with potentially concerning feature(s) per Fukuoka guidelines. Association and predictive power of specific features was examined via logistic mixed effects modeling and least absolute shrinkage and selection operator regression. RESULTS:Of the 2,686 patients diagnosed with intraductal papillary mucinous neoplasms, 460 (17.1%) had a feature of clinically relevant progression. Median follow-up was 7.1 years (interquartile range 2.99-11.9). Most (n = 365; 79%) were offered pancreatic resection with 230 (63%) undergoing resection. Sixty-nine (15.6%) developed invasive carcinoma. Endoscopic ultrasonography-guided cytology at diagnosis demonstrated a sensitivity of 28.4% (95% confidence interval 18.0%-40.7%) and specificity 98.9% (97.2%-99.7%) for high-risk pathology. Endoscopic ultrasonography-guided cytology after clinically relevant progression demonstrated a specificity of 100% (95% confidence interval 92.1%-100%) and sensitivity 16.1% (5.5%-33.7%).On mixed effects modeling, enhancing nodule (odds ratio 24.6, 95% confidence interval 6.58-91.74), main pancreatic duct involvement (odds ratio 4.77, 95% confidence interval 1.18-14.05), and symptoms (hazard ratio 12.139, 95% confidence interval 1.786-82.48) predicted high-risk pathology; other features, including size or size growth, did not (conditional pseudo-R2 = 0.218, marginal = 0.243). On least absolute shrinkage and selection operator analysis, enhancing nodule was the strongest predictor of both high-risk pathology and invasive carcinoma followed by main pancreatic duct dilatation and thick cyst wall. Age, body mass index, cyst size, and rate of size growth all had coefficients converging to zero. CONCLUSION:Enhancing nodule and any degree of main duct dilatation in an intraductal papillary mucinous neoplasm portend a high risk of malignant pathology, whereas cyst size and growth rate notably did not. These data should aid clinical management and might inform future practice guidelines.

The widespread use of modern, high-resolution cross-sectional imaging has led to increased detection of pancreatic cystic lesions (PCLs), which have varying malignant potential. While most require periodic radiographic surveillance, some warrant biopsy or surgical excision. We conducted a narrative review of the literature focusing on the diagnostic accuracy of imaging and the role of endoscopic and molecular tools in PCL evaluation. Cross-sectional imaging correctly classifies cyst type based on morphological features in approximately 50

ABSTRACTIntroductionPancreatic ductal adenocarcinoma (PDAC) of the body/tail is notably different than PDAC in the head of the pancreas. Surgery plus chemotherapy is known to improve outcomes for all PDAC. The sequence of this therapy is well studied in head cancers yet has never been evaluated systematically in relation to distal pancreatectomy (DP).MethodsPatients receiving DP for PDAC and who received chemotherapy were included. Patients were compared receiving neoadjuvant systemic therapy (NAST) only, adjuvant (AST) only, both NAST + AST, and who received total neoadjuvant therapy (TNT), defined as > 24 weeks NAST before DP. PSM was performed 1:1 between AST and each other group creating quadruplets of patients for analysis. Matching factors were determined by multivariate cox‐regression analysis of factors independently affecting survival. Survival was considered from diagnosis and from surgery to account for potential biases.ResultsIn total, 4677 patients were selected with 400 (8.6%) receiving TNT, 536 (11.5%) NAST, 3235 (69.2%) AST, and 506 (10.8%) NAST + AST. A total of 341 quadruplets were selected after PSM. There were no differences in comorbidities, T/N‐stage, retrieved or positive lymph nodes, and margin status after matching. Kaplan–Meier analysis showed no difference in median OS between the matched treatment groups (33.71 ± 2.07 vs. 35.22 ± 1.62 vs. 32.53 ± 3.31 vs. 37.88 ± 1.90, respectively; log‐rank p = 0.464). Five‐year OS was not different between the groups (21% vs. 18% vs. 20% vs. 25%, respectively; p = 0.501).ConclusionThe sequence of chemotherapy and surgery did not impact survival in distal PDAC. Providers should tailor an individualized approach designed to maximize the chance of completing both treatments.