Search Results (21)

Minimally invasive pancreas-preserving duodenal resection (MIPPDR) encompasses laparoscopic, robotic, and intentionally hybrid duodenal resections performed without pancreatic parenchymal excision, ranging from transduodenal local excision or ampullectomy to sleeve, segmental, subtotal, near-total, and total duodenectomy. This targeted narrative review was designed to provide a clinically oriented synthesis of the available literature on indications, operative strategies, platform selection, reconstruction, perioperative outcomes, oncological adequacy, and functional considerations. A structured literature search was performed in PubMed/MEDLINE, Scopus, and Web of Science up to March 2026. The review focused on minimally invasive or intentionally hybrid pancreas-preserving duodenal resections reporting operative technique, perioperative outcomes, oncological outcomes, or functional sequelae. The minimally invasive literature consisted predominantly of case reports, technical notes, video articles, and small retrospective series, with substantial heterogeneity in lesion type, anatomical location, procedure extent, reconstruction, and outcome reporting. Laparoscopy appeared most reproducible for distal, infra-papillary, and limited resections with relatively low reconstructive burden, whereas robotics appeared to offer specific technical advantages for periampullary dissection, ductal identification, and intracorporeal reconstruction. However, the available evidence was insufficient to define firm comparative indications between platforms or to demonstrate superiority of one minimally invasive approach over another. Functional outcomes, despite their central relevance to the rationale of pancreas preservation, were poorly standardized and inconsistently reported. MIPPDR was therefore interpreted as a selective pancreas-preserving strategy positioned between advanced endoscopic therapy and pancreaticoduodenectomy. Future studies should adopt anatomy-based reporting, distinguish ampullary, periampullary, and distal duodenal disease, and include standardized functional endpoints. Full article

Background/Objectives: Distal cholangiocarcinoma is a rare biliary tract cancer typically treated with pancreaticoduodenectomy. Comparative evidence specifically addressing minimally invasive versus open pancreaticoduodenectomy for this disease remains scarce. Methods: We conducted an updated systematic review and pairwise meta-analysis of comparative studies limited to distal cholangiocarcinoma. Binary outcomes were summarized as odds ratios, continuous outcomes as mean differences, and overall survival as hazard ratios. The primary survival analysis included only directly reported hazard ratios from prespecified matched or weighted cohorts; hazard ratios reconstructed from Kaplan–Meier curves were examined only in sensitivity analyses. Results: Six retrospective comparative studies involving 1623 patients met the inclusion criteria. Minimally invasive surgery was associated with lower blood loss (mean difference, −104.93 mL; 95% CI, −145.30 to −64.57; I² = 16.3%). No clear differences were found in clinically relevant postoperative pancreatic fistula (odds ratio, 1.03; 95% CI, 0.85 to 1.25), major morbidity (odds ratio, 0.96; 95% CI, 0.64 to 1.43), or R0 resection (odds ratio, 1.22; 95% CI, 0.96 to 1.56). In the primary overall survival analysis based on directly reported hazard ratios, the pooled hazard ratio was 0.93 (95% CI, 0.57 to 1.52; I² = 1.3%). In the sensitivity analysis incorporating eligible reconstructed hazard ratios, the pooled hazard ratio was 0.88 (95% CI, 0.73 to 1.05). In an exploratory recurrence-related survival family analysis based on directly reported estimates, the pooled hazard ratio was 0.95 (95% CI, 0.83 to 1.07; I² = 0.0%). Conclusions: Minimally invasive pancreaticoduodenectomy may reduce blood loss without clear evidence of worse major postoperative or oncologic outcomes in distal cholangiocarcinoma. However, the available evidence is entirely observational and should be interpreted with caution. Full article

Background: Pancreatic and periampullary cancers are common tumors of the digestive tract. As a radical surgical approach, laparoscopic pancreaticoduodenectomy requires crucial preoperative assessment of its surgical difficulty. Materials and methods: A retrospective cohort of 150 patients who underwent LPD between June 2019 and June 2023 was enrolled. The criteria for defining the difficult group were identified as unplanned conversion to open procedure, intraoperative blood loss, and operative time. Participants were randomly allocated to a training set (n = 105) or a testing set (n = 45) in a 7:3 ratio. Hand-crafted radiomics (HCR) features and deep learning-derived radiomics (DLR) features were extracted from portal venous phase CT images, focusing on gross tumor volume and gross peri-tumor volume. A hybrid prediction model was developed using a support vector machine algorithm, with performance evaluated through receiver operating characteristic analysis, calibration curves, and decision curve analysis (DCA). Results: The combined model demonstrated significantly superior discriminative ability, achieving an area under the curve (AUC) of 0.942 (95% CI: 0.893–0.992) in the training set and 0.848 (95% CI: 0.738–0.958) in the testing set. This performance exceeded both the standalone HCR model (testing AUC = 0.754) and the DLR model (testing AUC = 0.816). DCA further confirmed the clinical utility of the combined model, showing the highest net benefit across threshold probabilities exceeding 20%. Conclusions: The novel integrated model combining hand-crafted and deep learning-derived radiomics features enables effective prediction of surgical difficulty in laparoscopic pancreaticoduodenectomy. Full article

Background: Robotic pancreaticoduodenectomy (RPD) is a less invasive alternative to open pancreaticoduodenectomy (OPD) with the potential for perioperative advantage. Concerns remain regarding its technical difficulty, cost, and oncologic adequacy. Methods: Review of PubMed, MEDLINE, Scopus, and Embase databases was conducted (January 2000–October 2025), focusing on systematic reviews, meta-analyses, and significant comparative studies of RPD. Outcomes assessed were perioperative outcomes, oncologic sufficiency, learning curve, model training, cost-effectiveness, and future developments. Results: Several studies report comparable R0 rates and lymph node yield between RPD and OPD, with reduced blood loss, shorter postoperative hospital stay, and faster recovery in high-volume centers. Morbidity (35–50%) and 90-day mortality (<2%) are similar to open or laparoscopic surgery. Competence is usually achieved after 40–60 cases, while optimal outcomes are achieved after 80–100 procedures. Structured mentorship and simulation training improve safety and reproducibility. Novel technologies such as augmented reality, intraoperative fluorescence, and artificial intelligence-based navigation may also enhance accuracy and shorten the learning curve. Conclusions: RPD appears to be a safe and effective minimally invasive option in carefully selected patients if done in specialized, high-volume centers. Future studies need to resolve long-term oncologic results, cost-effectiveness, and the role of next-generation robotic systems. Full article

Background/Objectives: Textbook outcome (TO) is a composite quality measure in surgery, but few studies have compared TO between robotic pancreaticoduodenectomy (RPD) and laparoscopic pancreaticoduodenectomy (LPD). This study aimed to evaluate and compare TO following RPD and LPD for periampullary neoplasms. Methods: We retrospectively analyzed 322 patients who underwent minimally invasive PD between 2010 and 2023 (RPD, n = 60; LPD, n = 262). LPD was first introduced in 2004, but only cases performed since 2010 were included, while RPD has been performed since 2019. Propensity score matching (1:2) yielded 48 RPD and 96 LPD patients. TO was defined as the absence of pancreatic fistula, bile leak, post-pancreatectomy hemorrhage, severe complications (Clavien-Dindo ≥ III), readmission, and in-hospital or 30-day mortality. Results: In the entire cohort, 240 of 322 patients (74.5%) achieved TO. After matching, TO rates were 64.6% in RPD and 76.9% in LPD (p = 0.656). Perioperative outcomes, including operative time, blood loss, transfusion, hospital stay, and major complications, were comparable, although RPD showed a higher incidence of hemorrhage (p = 0.032). Multivariate analysis identified body mass index < 25 kg/m² as an independent predictor of achieving TO (OR 3.13, p = 0.008). Conclusions: RPD and LPD achieved comparable textbook outcomes in periampullary surgery. Both approaches are feasible when performed by experienced surgeons, but larger studies with long-term follow-up are needed to validate these findings. Full article

Background: Dissection around the superior mesenteric artery (SMA) is a key step for local clearance of periampullary cancers in pancreaticoduodenectomy (PD). Since the 2000s, SMA-first approaches have gained popularity in open surgery to allow early vascular control and resectability assessment. With the rise of robotic pancreaticoduodenectomy (RPD), various SMA dissection techniques have been adapted to the robotic setting. Objective: To map current evidence on SMA dissection techniques in RPD and summarize technical variations. Eligibility Criteria and Sources of Evidence: A PubMed search identified 116 records. After title and abstract screening and full-text review, 27 studies focusing on SMA dissection for periampullary tumors in RPD with sufficient technical detail were included. Studies on open/laparoscopic PD, lacking technical description, or reporting duplicate techniques were excluded. Charting Methods: Data were charted based on the SMA approach type, surgical details, and institution. Results: Among the 27 included studies, multiple approaches were identified—anterior, right posterior, left posterior, uncinate, and mesenteric—each adapted to the robotic platform. Techniques varied in exposure, lymphadenectomy, and vessel control. Conclusions: This scoping review reveals diverse SMA dissection strategies in RPD. While technical innovation is progressing, further studies are warranted to standardize approaches and assess their oncologic and surgical outcomes. Full article

Background and Objectives: Various publications have compared outcomes among open (OPDs), laparoscopic (LPDs), and robotic pancreaticoduodenectomies (RPDs); however, the number of randomized controlled trials (RCTs) remains limited. This study aims to conduct a systematic review and analyze the outcomes between these approaches from randomized controlled trials. Materials and Methods: We performed a systematic literature search across PubMed/MedLine, Cochrane Library, ClinicalTrials.gov, and Google Scholar to identify relevant RCTs. The systematic review was conducted using the reporting items for systematic reviews and network meta-analyses guidelines (PRISMA-NMA) and registered in Prospero (CRD420251024475). For statistical analysis R software (version 4.3.2) was used. Results: Eight RCTs involving 1416 patients (706 OPDs, 600 LPDs, 110 RPDs) were included. LPD had a significantly longer operative time than OPD, while RPD showed no significant difference compared to OPD. Blood loss was reduced in both minimally invasive approaches. LPD showed a higher R0 resection rate and lower pancreatic fistula rate, whereas RPD had the lowest mortality. No significant differences were observed in major complications, reoperation, or readmission. LPD shortened hospital stay; RPD showed no difference. Conclusions: Although open pancreaticoduodenectomy remains a well-established standard, both laparoscopic and robotic approaches offer safe alternatives with distinct advantages. LPD is associated with shorter hospital stay and lower pancreatic fistula rates, whereas RPD demonstrates the lowest mortality. The lack of direct randomized comparisons between LPD and RPD highlights the need for further head-to-head trials. Full article

Background: Reduced-port totally robotic pancreaticoduodenectomy (rpRPD) has been introduced to address limitations of conventional robotic pancreaticoduodenectomy (cRPD), particularly regarding assistant mobility and visualization. This study aimed to evaluate the clinical feasibility and procedural consistency of rpRPD in comparison with cRPD and laparoscopic pancreaticoduodenectomy (LPD). Methods: We conducted a retrospective cohort study of patients who underwent pancreaticoduodenectomy between January 2015 and December 2024. Patients were categorized into rpRPD (n = 40), cRPD (n = 60), and LPD (n = 262) groups. Clinical outcomes and learning curves were compared using regression and cumulative sum (CUSUM) analysis. Results: Baseline characteristics were similar across groups. The rpRPD group demonstrated significantly shorter operative time (p < 0.001) and lower blood loss (p < 0.05) than cRPD, with no significant differences in postoperative complications or hospital stay. The learning curve analysis revealed that rpRPD had lower variance (5839.3 vs. 8919.1) and more stable performance than cRPD despite a slightly longer stabilization point. Lymph node retrieval was comparable across groups, supporting oncological equivalence. Conclusions: rpRPD offers comparable perioperative and oncologic outcomes to cRPD and LPD while improving operative efficiency and procedural predictability. It represents a technically feasible and safe option for minimally invasive pancreatic surgery. Full article

Robotic pancreaticoduodenectomy (RPD) has emerged as a viable alternative to open and laparoscopic approaches, offering potential advantages in precision and dexterity. However, its complexity and lack of standardization remain as barriers to widespread adoption. We present a step-by-step surgical approach to RPD, emphasizing key technical strategies to enhance safety, efficiency, and reproducibility. Our technique is structured into defined surgical steps, facilitating learning curve optimization and intraoperative consistency. Key refinements include an optimized trocar placement, the strategic suspension of vascular structures, and specific reconstructive techniques to reduce the operative time and improve surgical ergonomics. These improvements may contribute to a reduction in perioperative morbidity and procedural standardization. Standardizing RPD through defined surgical steps and structured learning pathways may improve its feasibility, safety, and broader adoption. Further studies are needed to validate these strategies in high-volume centers. Full article

Iatrogenic ureteral strictures are uncommon but challenging to manage. We present our expertise in laparoscopic and robot-assisted laparoscopic ureteroureterostomy (LUU and RAUU) for lumbar and iliac strictures and laparoscopic ureteral reimplantation for pelvic strictures. A descriptive study was conducted on nine adult patients who underwent minimally invasive procedures. Six had lumbar or iliac ureteral strictures—five due to ureterorenoscopy and one following pancreaticoduodenectomy for pancreatic cancer. Three developed pelvic strictures after ureterorenoscopy. Preoperative evaluation included a medical history review, abdominal ultrasound, and CT scan. Success was characterized by the absence of symptoms and the lack of obstruction on follow-up imaging at one year. All procedures were technically feasible, with a median operating time of 105 min and a median hospital stay of four days. No major complications occurred. One patient experienced ureteral stricture recurrence following a laparoscopic approach for a lumbar stricture, and required a permanent double-J stent. At a median follow-up of 38 months, 88.88% of patients remained asymptomatic with preserved renal function. Our findings suggest that robotic and laparoscopic ureteral reconstruction performed by experienced surgeons at a tertiary center is a safe and effective option with a low complication rate. Full article

Background/Objectives: The aim of this study is to evaluate the impact of modified Blumgart anastomosis methods during pancreaticojejunostomy (PJ) on the incidence of clinically relevant postoperative pancreatic fistula (POPF) after laparoscopic pancreaticoduodenectomy (LPD). Methods: This is a retrospective cohort study analyzing data of patients who underwent LPD from 2018 to 2022. The primary endpoint was the incidence of grade B and C POPF based on the International Study Group on Pancreatic Fistula criteria and PJ anastomosis time. Incidence of postoperative complications (Clavien–Dindo classification grade ≥ III) was also investigated. Results: A total of 148 patients, 99 patients in a modified Blumgart group and 49 patients in a continuous suture group, were enrolled. There were no statistically significant differences in the general and intraoperative characteristics found between the two groups (p > 0.05). There was no significant difference in pancreas texture (p = 0.397) and diameter of pancreatic duct (p = 0.845). Grade B and C POPF occurred in five patients (5.1%) in the modified Blumgart group and three patients (6.1%) in the continuous suture group with no statistical difference (p = 0.781). A total of eleven patients (11.1%) in the modified Blumgart group and four patients (8.2%) in the continuous suture group had postoperative complication (Clavien–Dindo Classification grade 3 or more). Mortality within 90 days was 2 (2%) and 0 (0%), respectively. The PJ anastomosis times in the modified Blumgart group and continuous suture group were 28.8 ± 5.94 min and 35 ± 7.71 min, respectively (p = 0.003). Conclusions: This study suggests that modified Blumgart PJ showed shorter anastomosis time with comparable outcome to continuous suture methods in LPD. Full article

Objective: Postoperative pancreatic fistula (POPF) is a common and challenging complication following pancreaticoduodenectomy (PD), occurring in 2% to 46% of cases. Despite various pancreaticojejunostomy techniques, an effective method to prevent POPF has not been established. This study aimed to develop and evaluate a novel 3D-printed biodegradable pancreatic duct stent to simplify the surgical process of pancreaticojejunostomy, reduce anastomotic complexity, and minimize postoperative complications. Methods: Data from 32 patients undergoing total laparoscopic pancreaticoduodenectomy were utilized. Preoperative CT scans were transformed into 3D reconstructions to guide the design and printing of customized stents using polylactic acid (PLA). The stents were assessed for mechanical integrity, surface texture, and thermal stability. Animal experiments were conducted on 16 mini pigs, with the experimental group receiving the novel stent and the control group receiving traditional silicone stents. Results: The 3D-printed stents demonstrated accurate dimensional replication and mechanical reliability. In the animal experiments, the experimental group showed no significant difference in postoperative complications compared to the control group. At 4 weeks post-surgery, CT scans revealed well-healed anastomoses in both groups, with no significant inflammation or other complications. Histological examination and 3D reconstruction models confirmed good healing and device positioning in the experimental group. Conclusion: The 3D-printed biodegradable pancreatic duct stent offers a promising solution for pancreaticojejunostomy, with comparable safety and efficacy to traditional methods. Further research is needed to validate its clinical application. Full article

Background: Pancreatic neuroendocrine tumors (pNETs) represent a rare subset of pancreatic cancer. Functional tumors cause hormonal changes and clinical syndromes, while non-functional ones are often diagnosed late. Surgical management needs multidisciplinary planning, involving enucleation, distal pancreatectomy with or without spleen preservation, central pancreatectomy, pancreaticoduodenectomy or total pancreatectomy. Minimally invasive approaches have increased in the last decade compared to the open technique. The aim of this study was to analyze the current diagnostic and surgical trends for pNETs, to identify better interventions and their outcomes. Methods: The study adhered to the PRISMA guidelines, conducting a systematic review of the literature from May 2008 to March 2022 across multiple databases. Several combinations of keywords were used (“NET”, “pancreatic”, “surgery”, “laparoscopic”, “minimally invasive”, “robotic”, “enucleation”, “parenchyma sparing”) and relevant article references were manually checked. The manuscript quality was evaluated. Results: The study screened 3867 manuscripts and twelve studies were selected, primarily from Italy, the United States, and China. A total of 7767 surgically treated patients were collected from 160 included centers. The mean age was 56.3 y.o. Enucleation (EN) and distal pancreatectomy (DP) were the most commonly performed surgeries and represented 43.4% and 38.6% of the total interventions, respectively. Pancreatic fistulae, postoperative bleeding, re-operation, and follow-up were recorded and analyzed. Conclusions: Enucleation shows better postoperative outcomes and lower mortality rates compared to pancreaticoduodenectomy (PD) or distal pancreatectomy (DP), despite the similar risks of postoperative pancreatic fistulae (POPF). DP is preferred over enucleation for the pancreas body–tail, while laparoscopic enucleation is better for head pNETs. Full article

Background and Aims: Pancreaticoduodenectomy (PD) is a complex and high-skill demanding procedure often associated with significant morbidity and mortality. However, the results have improved over the past two decades. However, there is a paucity of research concerning the learning curve for PD. Our aim was to report the outcomes of 100 consecutive PDs representing a single surgeon’s learning curve and to depict the factors that influenced the learning process. Methods: We reviewed the first 121 PDs performed at our academic center (2013–2019) by a single surgeon; 110 were PDs (5 laparoscopic and 105 open) and 11 were total PDs (1 laparoscopic and 10 open). Subsequent statistics was performed on the first 100 PDs, with attention paid to the learning curve and survival rate at 5 years. The data were analyzed comparing the first 50 cases (Group 1) to the last 50 cases (Group 2). Results: The most frequent histopathological tumor type was pancreatic ductal adenocarcinoma (50%). A total of 39% of patients had preoperative biliary drainage and 45% presented with positive biliary cultures. The preferred reconstruction technique included pancreaticogastrostomy (99%), in situ hepaticojejunostomy (70%), and precolic gastro-jejunal anastomosis (88%). Postoperative complications included biliary fistula (1%), pancreatic fistula (8%), pancreatic stump bleeding (4%), and delayed gastric emptying (13%). The mean operative time decreased after the first 50 cases (p < 0.001) and blood loss after 60 cases (p = 0.046). R1 resections lowered after 25 cases (p = 0.025). Vascular resections (17%) did not influence the rate of complications (p = 0.8). The survival rate at 5 years for pancreatic adenocarcinoma was 32.93%. Conclusions: Outcomes improve as surgeon experience increases, with proper training being the most important factor for minimizing the impact of the learning curve over the postoperative complications. Analyzing the learning curve from the perspective of a single surgeon is mandatory for accurate statistical results and interpretation. Full article

(1) Background: With ageing, the number of pancreaticoduodenectomies (PD) for benign or malignant disease is expected to increase in elderly patients. However, whether minimally invasive pancreaticoduodenectomy (MIPD) should be performed in the elderly is not clear yet and it is still debated. (2) Materials and Methods: A systematic review and meta-analysis was conducted including seven published articles comparing the technical and post-operative outcomes of MIPD in elderly versus younger patients up to December 2022. (3) Results: In total, 1378 patients were included in the meta-analysis. In term of overall and Clavien–Dindo I/II complication rates, post-operative pancreatic fistula (POPF) grade > A rates and biliary leakage, abdominal collection, post-operative bleeding and delayed gastric emptying rates, no differences emerged between the two groups. However, this study showed slightly higher intraoperative blood loss [MD 43.41, (95%CI 14.45, 72.38) p = 0.003], Clavien–Dindo ≥ III complication rates [OR 1.87, (95%CI 1.13, 3.11) p = 0.02] and mortality rates [OR 2.61, (95%CI 1.20, 5.68) p = 0.02] in the elderly compared with the younger group. Interestingly, as a minor endpoint, no differences in terms of the mean number of harvested lymphnode and of R0 resection rates were found. (4) Conclusion: MIPD seems to be relatively safe; however, there are slightly higher major morbidity, lung complication and mortality rates in elderly patients, who potentially represent the individuals that may benefit the most from the minimally invasive approach. Full article