Search Results (299)

The digitization of healthcare has enabled the application of advanced analytics, such as process mining and machine learning, to electronic health records (EHRs). This study aims to identify workflow inefficiencies, temporal bottlenecks, and risk factors for delayed recovery in surgical pathways using the open-access MOVER dataset. A multi-stage framework was implemented, including heuristic control-flow discovery, Petri net-based conformance checking, temporal performance analysis, unsupervised clustering, and Random Forest-based classification. All analyses were simulated on pre-discharge (“preliminary”) patient records to enhance real-time applicability. Control-flow models revealed deviations from expected pathways and issues with data quality. Conformance checking yielded perfect fitness (1.0) and moderate precision (0.46), indicating that the model generalizes despite clinical variability. Stratified performance analysis exposed duration differences across ASA scores and age groups. Clustering revealed latent patient subgroups with distinct perioperative timelines. The predictive model achieved 90.33% accuracy, though recall for delayed recovery cases was limited (24.23%), reflecting class imbalance challenges. Key features included procedural delays, ICU status, and ASA classification. This study highlights the translational potential of integrating process mining and predictive modeling to optimize perioperative workflows, stratify recovery risk, and plan resources. Full article

Background: The Geriatric Nutritional Risk Index (GNRI) is a simple tool for nutritional assessment, but its long-term prognostic value in patients undergoing pancreaticoduodenectomy (PD) remains unclear. Methods: This retrospective study included adult patients who underwent PD between January 2014 and December 2023 at Chang Gung Memorial Hospital. Patients were grouped by GNRI: inferior (<82), moderate (82–98), and superior (≥98). Propensity score matching was performed based on age, sex, cancer type, surgical approach, and ASA status. Primary outcomes were overall survival (OS) and recurrence-free survival (RFS). Results: Among 371 patients, inferior GNRI was associated with worse median survival time (18.64 vs. 34.62 months, HR = 2.953, p < 0.001). This association was observed in both pancreatic cancer and other periampullary malignancies. Inferior GNRI also correlated with higher short-term mortality and adverse perioperative outcomes, including longer ICU stay, and greater need for ventilator support, reintubation, reoperation and total parenteral nutrition (TPN). Conclusions: Preoperative GNRI is a strong predictor of survival and short-term outcomes in PD patients. Early nutritional assessment may aid risk stratification and intervention. Full article

Background and Objectives: The erector spinae plane block (ESPB) is an emerging regional anesthesia technique that has demonstrated effectiveness in reducing postoperative pain and opioid consumption following laparoscopic cholecystectomy (LC). However, the optimal timing of ESPB whether administered preoperatively or postoperatively remains uncertain, particularly regarding its influence on intraoperative hemodynamic stability and procedural feasibility. This study aimed to compare the analgesic efficacy, intraoperative hemodynamic profiles, and procedural advantages of preoperative versus postoperative ESPB in patients undergoing elective LC. Materials and Methods: In this prospective, randomized, and single-blind clinical trial, 80 ASA I–II adult patients scheduled for elective LC were randomly assigned to receive bilateral ESPB either before anesthesia induction (Group 1) or immediately after surgery but prior to extubation (Group 2). All patients received standardized general anesthesia. The primary outcome was postoperative pain measured by the numeric rating scale (NRS) at 2 h postoperatively. Secondary outcomes included NRS scores at other time points (0, 4, 6, 12, and 24 h), intraoperative and postoperative hemodynamic parameters, cumulative 24 h rescue analgesic consumption, patient satisfaction scores, and adverse events. Results: Both groups experienced significant reductions in postoperative NRS scores, with no statistically significant differences between groups in pain intensity or tramadol consumption. However, the preoperative ESPB group exhibited significantly more stable intraoperative blood pressure readings, particularly at 30 and 60 min after incision and at extubation. No ESPB-related complications occurred in either group. Patient satisfaction levels were comparable across groups. Conclusions: Preoperative and postoperative ESPBs offer comparable analgesic efficacy and opioid sparing effects in LC. However, preoperative ESPB provides enhanced intraoperative hemodynamic stability and avoids the logistical challenges of performing blocks under anesthesia, including repositioning related risks. These findings suggest that preoperative ESPB may be considered for integration into enhanced recovery after surgery (ERAS) protocols for minimally invasive biliary surgery, pending further large-scale multicenter trials. Full article

Background: Hip fractures are common in the elderly and often require ICU admission post-surgery due to high ASA scores and comorbidities. Length of hospital stay after ICU is a crucial indicator affecting patient recovery, complication rates, and healthcare costs. This study aimed to develop and validate a machine learning-based model to predict the factors associated with extended hospital stay (>7 days from surgery to discharge) in hip fracture patients requiring postoperative ICU care. The findings could help clinicians optimize ICU bed utilization and improve patient management strategies. Methods: In this retrospective single-centre cohort study conducted in a tertiary ICU in Turkey (2017–2024), 366 ICU-admitted hip fracture patients were analysed. Conventional statistical analyses were performed using SPSS 29, including Mann–Whitney U and chi-squared tests. To identify independent predictors associated with extended hospital stay, Least Absolute Shrinkage and Selection Operator (LASSO) regression was applied for variable selection, followed by multivariate binary logistic regression analysis. In addition, machine learning models (binary logistic regression, random forest (RF), extreme gradient boosting (XGBoost) and decision tree (DT)) were trained to predict the likelihood of extended hospital stay, defined as the total number of days from the date of surgery until hospital discharge, including both ICU and subsequent ward stay. Model performance was evaluated using AUROC, F1 score, accuracy, precision, recall, and Brier score. SHAP (SHapley Additive exPlanations) values were used to interpret feature contributions in the XGBoost model. Results: The XGBoost model showed the best performance, except for precision. The XGBoost model gave an AUROC of 0.80, precision of 0.67, recall of 0.92, F1 score of 0.78, accuracy of 0.71 and Brier score of 0.18. According to SHAP analysis, time from fracture to surgery, hypoalbuminaemia and ASA score were the variables that most affected the length of stay of hospitalisation. Conclusions: The developed machine learning model successfully classified hip fracture patients into short and extended hospital stay groups following postoperative intensive care. This classification model has the potential to aid in patient flow management, resource allocation, and clinical decision support. External validation will further strengthen its applicability across different settings. Full article

Background: Pilon fractures are severe distal tibia injuries from high-energy trauma, often involving joint and soft tissue damage. Despite surgical advances, long-term outcomes remain poor. This study compared quality of life and functional limitations after surgical treatment of pilon versus tibial shaft fractures using validated PROMs. Methods: This case–control study was conducted at a Level I Trauma Center. Between 2016 and 2019, 84 patients with lower leg fractures were included: 38 pilon and 46 tibial shaft fractures. Inclusion criteria were AO type 42 or 43 fractures and follow-up of ≥24 months; exclusion criteria were polytrauma (ISS > 15), ASA ≥ 3, and incomplete consent. Outcomes were assessed with SF-12, EQ-5D-5L, and VAS-FA. Data were collected 36–48 months postoperatively. Analyses included t-tests, chi-square tests, linear regression. Results: Patients with pilon fractures had significantly poorer physical quality of life than tibial shaft fractures (SF-12 physical: 39 vs. 42, p < 0.05). Mental quality of life showed no significant difference. EQ-5D-5L scores were lower in the pilon group (70% vs. 79%). VAS-FA indicated higher pain and reduced function (total: 64 vs. 76, p = 0.009). Rehabilitation duration correlated with improved VAS outcomes in pilon fractures (p = 0.008), while physiotherapy reduced pain in tibial shaft fractures (p = 0.030). Conclusions: Pilon fractures substantially impair physical quality of life and long-term function, while mental well-being remains unaffected. PROMs provide insights beyond radiological findings and should be integrated into follow-up. Further multicenter studies are required to validate these results and optimize rehabilitation strategies. Full article

Background and Objectives: This study aimed to evaluate the predictive value of systemic inflammatory response markers—namely, the Systemic Inflammatory Response Index (SIRI), Aggregate Index of Systemic Inflammation (AISI), and Monocyte-to-Lymphocyte Ratio (MLR)—in determining the occurrence of major complications following radical cystectomy. Materials and Methods: A retrospective analysis was conducted on 200 patients who underwent open radical cystectomy with ileal conduit diversion. Demographic, clinical, and laboratory variables, including albumin, creatinine, eGFR, smoking, and ASA score, were collected. SIRI, AISI, and MLR were calculated from preoperative blood counts. Major complications and their subtypes (infectious, wound, cardiopulmonary, thrombotic, and anastomotic) were adjudicated independently. Statistical analyses included multivariable logistic regression, ROC curves, calibration (Hosmer–Lemeshow, intercept, slope, and plots), bootstrap resampling (B = 2000), linearity checks (restricted cubic splines and Box–Tidwell), incremental value metrics (ΔAUC, IDI, and NRI), and decision-curve analysis (DCA). Results: Major complications occurred in 57 patients (28.5%). SIRI values were significantly higher in patients with major complications (median 2.12 vs. 1.63, p = 0.006), whereas AISI and MLR did not differ. SIRI remained an independent predictor in multivariable analysis (OR 1.37, 95% CI 1.01–1.86, p = 0.045). An AUC of 0.624 (95% CI 0.538–0.709) with a negative predictive value of 83.3% was observed for SIRI. The baseline clinical model yielded an AUC of 0.648, and an AUC of 0.672 was obtained when SIRI was added (ΔAUC = +0.024, 95% CI −0.022–0.071, p = 0.16). Calibration was excellent (intercept = 0.07, slope = 1.08), and superior net benefit was demonstrated for the SIRI-augmented model within threshold probabilities of 0.15–0.45 in DCA. A statistically significant improvement in IDI (0.024, p = 0.024) was identified, while NRI was positive but not significant. Subtype analyses indicated that the strongest associations of SIRI were with infectious and wound complications. Conclusions: SIRI was found to be an independent predictor of major complications after open radical cystectomy. Although gains in discrimination were modest, incremental analyses demonstrated improved calibration and net clinical benefit when SIRI was incorporated into a clinical model. External validation is required before translation into clinical practice. Full article

Background and Objectives: This study aimed to evaluate surgical outcomes and identify prognostic factors associated with anastomotic leakage (AL), following rectal cancer resection. Materials and Methods: A retrospective cohort study included 415 patients who underwent rectal cancer surgery between 2020 and 2024. Patients were categorized by surgical approach (laparoscopic vs. open) and presence of AL. Results: Of the 415 patients, 160 (38.6%) underwent laparoscopic surgery, and 255 (61.4%) underwent open surgery. Operative time was significantly longer for laparoscopic surgery (213.0 ± 65.9 vs. 201.3 ± 60.4 min, p = 0.05), while stoma formation was more frequent in the open surgery group (60.0% vs. 48.1%, p = 0.018). Reoperation rate was higher in the laparoscopic group compared to the open group (13.1% vs. 6.7%, p = 0.027). The rate of AL was 20.5% in the laparoscopic group and 18.4% in the open surgery group (p = 0.434). Patients with AL had a significantly longer hospital stay (17 days, IQR 12.0–23.7 vs. 8 days, IQR 7.0–9.0, p < 0.001). The use of NOACs was associated with an increased risk of AL (p = 0.026). Multivariate analysis revealed that both a higher ASA score (p = 0.022) and older age (p = 0.044) were independent risk factors for AL, while the use of a diverting ileostomy was associated with a threefold reduction in the risk of AL (p = 0.049). Conclusions: AL rates were similar between approaches. Laparoscopic surgery had more reoperations and longer operative times. AL was associated with NOAC use, older age, and higher ASA scores. Diverting ileostomy reduced AL risk and warrants broader use in high-risk patients to improve outcomes. Full article

Background and Objectives: This study compares laparoscopic and robotic surgical techniques for rectal cancer, focusing on oncologic outcomes, mesocolic excision quality, lymph node yield, and postoperative sexual and urinary function, while also exploring patient satisfaction and recovery trajectories through clinical outcomes and validated questionnaires. Materials and Methods: A retrospective analysis was conducted on 100 patients who underwent rectal cancer surgery between 2017 and 2021 at our tertiary center—53 underwent laparoscopic and 47 robotic surgery. Demographic data, tumor characteristics, and surgical details (procedure type, lymph node yield, morbidity, and mortality) were collected, and postoperative outcomes, including local recurrence, metastasis, need for reoperation, urinary incontinence, and sexual dysfunction, were compared. Functional outcomes were evaluated using the LARS questionnaire, Wexner score, IPSS, IIEF, and FSFI. Results: No significant differences were found in age, BMI, tumor size, or ASA scores between groups. Robotic surgery was associated with shorter hospital stays (p < 0.001), no conversions to open surgery (vs. 28.3% in laparoscopy), and zero cases of positive circumferential margins (vs. 35.8% in laparoscopy; p < 0.001). Lymphatic and perineural invasion rates were similar. Tumor recurrence occurred in four robotic and six laparoscopic cases, and factors significantly associated with recurrence included pathological stage, hospital stay, and adjuvant treatment. Robotic surgery showed improved urinary and sexual function, with lower Wexner, IPSS, and FSFI scores. Conclusions: Robotic surgery is a safe, effective, and patient-friendly alternative to laparoscopy, offering better preservation of continence and sexual function, reduced conversion rates, and shorter hospitalization, and should be considered the preferred approach in appropriately selected rectal cancer patients. Full article

Background/Objectives: The optimal surgical approach for stage I renal cell carcinoma (RCC) in ultra-octogenarians remains debated, especially when balancing oncologic control, renal preservation, and procedural safety. While ablative techniques and active surveillance are often favored in frail patients, robust comparative evidence supporting nephron-sparing surgery in this age group is limited. Methods: We retrospectively reviewed consecutive patients aged ≥80 years who underwent minimally invasive surgery for cT1 clear cell RCC at a high-volume tertiary-care center between July 2001 and August 2025. Patients were stratified into two cohorts: minimally invasive partial nephrectomy (MIPN, n = 51) and radical nephrectomy (MIRN, n = 26). All MIPNs were performed using an off-clamp approach. Baseline, perioperative, functional, and oncologic outcomes were compared. Kaplan–Meier analysis estimated overall survival (OS), cancer-specific survival (CSS), and progression to significant chronic kidney disease (sCKD, defined as CKD stage ≥ 3b). Results: Groups were comparable in age, comorbidities, and ASA score. MIRN patients exhibited higher tumor complexity (RENAL score: 9 vs. 7, p = 0.01) and a greater proportion of pT1b lesions (77% vs. 37.3%, p = 0.01). Perioperative transfusions occurred exclusively in the MIRN group (p = 0.01), whereas complication rates were low and similar between groups. MIPN was associated with significantly higher eGFR at follow-up (48 vs. 30.9 mL/min/1.73 m², p = 0.01) and a delayed progression to sCKD (p = 0.01), with no differences in OS or CSS at a median follow-up of 30.5 months. Conclusions: In this real-world series of ultra-octogenarians with cT1 clear cell RCC, off-clamp minimally invasive partial nephrectomy ensured superior renal function preservation and delayed progression to sCKD, without compromising oncologic control at mid-term follow-up. Beyond statistical outcomes, these results underscore the importance of tailoring surgical strategies to protect long-term functional autonomy and preserve physiological resilience in elderly patients. Full article

Background: Achalasia is a primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis, which increases the risk of aspiration during anesthesia. Peroral endoscopic myotomy (POEM) is a minimally invasive therapeutic approach requiring tailored anesthetic management. This study aimed to evaluate perioperative anesthesia management during POEM, focusing on ventilation parameters, intraoperative hemodynamics, laboratory changes, and the incidence and severity of postoperative complications. Methods: A retrospective analysis was conducted on 51 patients who underwent POEM between June 2016 and April 2025. Demographic features, anesthesia techniques, intraoperative physiologic parameters, hematologic profiles, and postoperative complications were evaluated. Standard preoperative fasting protocols were implemented. Rapid sequence induction (RSI) with propofol and rocuronium was followed by endotracheal intubation. Desflurane was used for maintenance anesthesia, with ventilation settings adjusted to limit end-tidal carbon dioxide (ETCO₂) elevation. Results: The median age of patients was 48 years, with a slight female (52.9%) predominance. Most patients were American Society of Anesthesiologists (ASA) II (64.7%) or ASA III (35.3%) scores and had comorbid hypertension (31.4%) or diabetes (11.8%). The median anesthesia duration was 180 min, and the peak inspiratory pressure remained stable at 25 mmHg. Oxygen saturation (SpO₂) improved during the procedure, while ETCO₂ increased from baseline to 49 mmHg by the end. Blood pressure declined transiently but recovered intraoperatively. Hematologic analysis showed significant increases in white blood cell (WBC) and neutrophils and mild decreases in hemoglobin, hematocrit, and platelets. Early postoperative complications included subcutaneous emphysema (19.6%), minor bleeding (9.8%), and pneumoperitoneum (7.84%). Two patients required tube thoracostomy due to pneumothorax, but no patient developed a complication requiring surgical exploration. During a median follow-up of 546 days, no mortality was reported. Long-term complications were infrequent, with gastroesophageal reflux disease (GERD) (3.92%) and esophagitis (1.96%) being the most notable. Conclusions: POEM can be performed safely with appropriate anesthetic management. Despite significant physiologic changes during carbon dioxide (CO₂) insufflation, no life-threatening complications occurred, and the majority of adverse events were minor and self-limiting. Close intraoperative monitoring and interdisciplinary coordination contribute to favorable perioperative outcomes. Full article

Introduction: Diverticular disease is common in Western countries, and the frequency of emergency operations for acute left-sided complicated diverticulitis (ALCD) has increased over the past 15 years. Methods: A total of 49 patients aged over 80 years and 125 younger patients who underwent emergency surgery for ALCD between October 2018 and June 2025 were analyzed. Demographics and postoperative outcomes were compared between the groups. Multivariate logistic regression was used to assess the association between age and postoperative morbidity and mortality. A separate regression model was used to identify risk factors for postoperative mortality and morbidity, specifically in elderly patients. Results: Significant differences between the two groups were found in sex distribution (p < 0.001), cardiovascular comorbidities (p < 0.001), chronic renal insufficiency (CRI) (p < 0.001), ASA score (p < 0.001), ALCD severity according to the modified Hinchey classification (p = 0.006), Mannheim Peritonitis Index (MPI) (p = 0.021), postoperative complications (p < 0.001), and 90-day mortality rates (p < 0.001). Advanced age was a significant predictor of 90-day postoperative mortality and morbidity. In the elderly subgroup, an ASA score ≥ 3, MPI > 25, CRI, and COPD were identified as independent predictors of 90-day postoperative mortality and morbidity. Conclusions: Advanced age is an independent risk factor for 90-day postoperative mortality and morbidity following emergency surgery for ALCD. In patients over 80 years, an ASA score ≥ 3, CRI, COPD, and MPI ≥ 25 are associated with a poorer prognosis. Full article

Background/Objectives: Nutritional status affects postoperative outcomes, but the effect of standardized preoperative nutritional preparation on morbidity in malnourished patients undergoing pancreatoduodenectomy (PD) remains unclear. This study evaluated preoperative nutritional parameters following the standardization of nutritional screening and intervention in patients undergoing PD. The influence of nutritional parameters on postoperative morbidity was also assessed. Methods: This prospective cohort study was conducted from 2019 to 2021 at the Department of Surgery, University Hospital, Olomouc. A total of 133 patients were categorized nutritionally as “high risk” (weight loss or reduced appetite with restricted intake) or “low risk” (no weight or appetite loss). High-risk patients received enteral supplementation of 600 kcal/day. A multivariate logistic regression model was used to evaluate the association between major postoperative complications and risk factors, including sex, age, ASA score, BMI, weight and appetite loss, malignancy, duct diameter, pancreatic texture, serum albumin, prealbumin, MUST, and NRS2002 scores. Results: Eighty patients (60.2%) were “high risk,” and 53 (39.8%) were “low risk.” Major morbidity and 90-day mortality occurred in 24 (18.0%) and 4 (3.0%) patients, respectively. No significant differences were observed between high- and low-risk groups in CD morbidity grade, 90-day mortality, POPF, PPH, DGE, or hospital stay. Major morbidity was associated with prealbumin < 0.2 g/L, duct diameter ≤ 3 mm, soft texture, and male sex, with respective odds ratios of 3.307, 3.288, 4.814, and 2.374. Conclusions: High-risk patients receiving preoperative nutrition had comparable rates of major complications and POPF as low-risk patients. Low serum prealbumin predicts major postoperative complications after PD. Full article

Introduction: The management of peri-operative pain significantly impacts the post-operative recovery following kidney transplant. For decades, regional blocks have been utilized for post-operative pain management following abdominal surgery. The data on the routine use of regional blocks peri-operatively during kidney transplants are limited. We aim to review our current clinical practice of peri-operative use of regional blocks during kidney transplants and management of peri-operative pain up to 24 h. Methods: A consecutive series of 100 patients who underwent kidney transplant was reviewed. All demographic data including patient’s age, gender, race, and body mass index were collected. Pre-transplant co-morbidities were summarized for all patients and included the American Society of Anesthesiologists (ASA) score. Patients were divided into two groups based on whether they received a transversus abdominis plane (TAP) block. Group A consisted of patients who received an ultrasound-guided TAP block, while Group B included patients who did not receive any form of TAP block. The intra-operative and post-operative use of analgesia was recorded for up to 24 h post kidney transplant. All peri-operative complications were reviewed. The chi-square test and Fisher’s exact test was used to compare symptoms (nausea, vomiting, and pruritus) between the two groups. Similarly, the use of analgesia was also compared. Results: A total of 100 patients were identified and equally distributed between the two groups [Group A = 50 (TAP block), Group B = 50 (non-TAP block)]. There was a statistically significant reduction in the use of intraoperative fentanyl (p = 0.04) in Group A. There was no difference in the post-operative use of hydromorphone (p = 0.665), oxycodone (p = 0.75), and acetaminophen (p = 0.64) up to 24 h after the kidney transplant procedure. There was no difference between post-operative nausea (p = 0.766), vomiting (p = 0.436), and pruritus. There were no complications recorded secondary to the use of regional blocks in Group A. Conclusions: The use of regional anesthesia in kidney transplant recipients is a safe approach without complications. The study concluded that regional blocks decrease the use of intra-operative opioids. However, there was no difference in the use of post-operative requirements for analgesia or side effects up to 24 h after kidney transplant. Full article

Background: Efficient and safe discharge is critical in pediatric dental procedures performed under deep sedation in non-operating room anesthesia (NORA) settings. Traditional institutional criteria may delay discharge due to subjectivity. Objective: This study compared the Modified Aldrete Recovery Score (MAS) and institutional discharge criteria to determine which provides faster and reliable discharge decisions. Methods: In this prospective observational study, 100 children (ages 2–10, ASA I–III) undergoing deep sedation for dental treatment were evaluated. Two nurse anesthetists independently assessed discharge readiness every five minutes using either MAS or institutional criteria. Demographic data, BMI percentile, ASA class, anesthesia duration, and propofol dose were recorded. Discharge times were compared using Wilcoxon signed-rank and subgroup analyses and correlation tests. Results: MAS allowed significantly earlier discharge than institutional criteria (24.75 ± 7.33 vs. 36.79 ± 8.59 min, p = 0.01). The agreement between methods was poor (ICC = 0.06). Discharge time varied significantly by BMI percentile (p = 0.01); obese children had shorter recovery times, while time differences were greater in overweight children. No adverse events or readmissions occurred. Conclusions: MAS provides a quicker and equally safe discharge assessment in pediatric dental sedation. Its use may enhance workflow efficiency and standardize recovery decisions in NORA settings lacking formal PACUs. Full article

Background/Objectives: Like many other countries, the management of pancreatic cancer in Spain has developed in a fragmented manner. This study analyzes clinical outcomes related to patient volume at different centers after left pancreatectomy (LP). Our goal is to determine whether our practices align with the standards established in the literature and assess whether centralization’s advantages significantly outweigh its disadvantages. Methods: The SPANDISPAN Project (SPANish DIStal PANcreatectomy) is an observational, prospective, multicenter study focused on LP conducted in Spanish Hepato-Pancreato-Biliary (HPB) Surgery Units from 1 February 2022 to 31 January 2023. HPB units were defined as high volume if they performed more than 10 LPs annually. Results: This study included 313 patients who underwent LP at 42 centers across Spain over the course of a year. A total of 40.3% of the procedures were performed in high-volume centers. Significant differences in preoperative variables were only observed in ASA scores, which were higher in the high-volume group. Intraoperatively, minimally invasive surgical techniques were performed more frequently in high-volume centers. Postoperatively, the administration of somatostatin, major complications, and B and C postoperative pancreatic fistula (POPF) were more frequent in low-volume hospitals. Conclusions: The findings revealed that high-volume centers had a higher rate of minimally invasive surgery, lower intraoperative bleeding, fewer complications, and reduced POPFs compared to low-volume centers. However, it is important to note that low-volume centers still demonstrated acceptable outcomes. Thus, the selective referral of more complex laparoscopic procedures could initiate a gradual centralization of surgical practices. Full article