Search Results (123)

Background: Pancreatic fistula remains the leading cause of morbidity after pancreaticoduodenectomy. However, its diagnosis is frequently delayed. We evaluate the predictive accuracy of serum lipase in detecting a clinically relevant pancreatic fistula (CR-POPF) and assess whether its combination with procalcitonin (PCT) improves risk stratification. Methods: A single-center study was conducted that included 115 patients who underwent pancreaticoduodenectomy between 2015 and 2019. Serum lipase levels were measured preoperatively and on postoperative day (POD) 1, 2, and 3. Elevated lipase was defined as >3× the institutional upper limit of normal (>177 U/L). Results: Serum lipase levels were higher in patients who developed CR-POPF at all postoperative days (p < 0.01). The area under the curve (AUC) increased from POD 1 (0.76) to POD 2 (0.82) and remained stable at POD 3 (0.82), while specificity improved from 52.7% to 89.2%, with consistently high negative predictive values (92.5–93.3%). Elevated lipase on POD 3 predicts CR-POPF (OR 6.89, 95% CI 1.61–29.53; p = 0.009). The combination of elevated lipase, regardless of the preoperative value, and PCT ≥ 1.5 ng/mL on POD 3 achieved full specificity. Conclusions: Early postoperative serum lipase levels are useful to exclude CR-POPF after pancreaticoduodenectomy. POD 3 provided a proper diagnostic value. The combination of serum lipase and PCT on POD 3 may further improve accuracy, enabling tailored postoperative surveillance. Full article

Postpancreatectomy acute pancreatitis grade C (PPAP-C) is the most severe grade of this complication, associated with the highest mortality rate after pancreatoduodenectomy (PD). Most PPAP-C cases require surgical intervention. However, no treatment guidelines for PPAP-C have been established. Literature reports are largely based on the coexistence of postoperative pancreatic fistula grade C (POPF-C) and PPAP-C, with similar surgical treatment methods. However, in PPAP-C, the evolution of inflammation can vary in course and severity: from necrosis limited to the anastomotic line to extensive necrosis involving the entire pancreatic parenchyma. In this narrative review, we summarize the surgical techniques proposed for PPAP-C treatment and attempt to create a decision-making algorithm for optimizing the choice of surgical treatment for PPAP-C depending on the extent of pancreatic necrosis and the patient’s general condition after PD. Our retrospective review is largely based on retrospective evidence and contains an inevitable selection bias. According to the cited literature, in cases of limited necrosis, parenchyma-sparing methods show an advantage over completion pancreatectomy. However, the complete pancreatic removal is usually performed in the initially more advanced cases or as a second choice when the pancreas-preserving methods fail. Therefore, the superiority of any approach cannot be clearly determined. More studies and uniform guidelines for optimal PPAP-C treatment are needed. Full article

Background: Palliative surgery is often considered for advanced stages of gastric cancer to reduce symptoms and improve quality of life; however, it is associated with considerable risks of postoperative complications and mortality. The aim of this study is to analyze the differences in severe complication rates and mortality between palliative and curative gastric cancer surgeries using data from a nationwide survey conducted by the Korean Gastric Cancer Association. Materials and Methods: Data from 12,420 patients who underwent gastric cancer surgery in 2019 were analyzed. Surgical procedures were categorized as total gastrectomies (TGs), distal gastrectomies (DGs), or bypass operations. Patients were divided into curative gastrectomy (CG, n = 12,114) and palliative surgery (PS, n = 306) groups. Postoperative complications were classified using the Clavien–Dindo (C-D) classification. Severe complications were defined as C-D grade IIIa or higher. Results: Compared with the CG group, the PS group had significantly higher rates of severe complications (10.2% vs. 4.8%, p < 0.001) and mortality (1.6% vs. 0.2%, p = 0.001). Leakage (3.9% vs. 1.3%, p = 0.001) and pancreatic fistula (1% vs. 0.2%, p = 0.036) were significantly more common in the PS group. When compared by resection extent, the PS group had higher severe complication rates than the CG group for DGs (13% vs. 3.8%, p < 0.001) and a higher mortality rate for TGs (3.3% vs. 0.3%, p = 0.006). Conclusions: Palliative gastric cancer surgeries are associated with significantly higher rates of severe complications and mortality than are curative surgeries. These findings emphasize the need for careful patient selection and thorough preoperative counseling when considering palliative gastric cancer surgery. Full article

Background: Solid pseudopapillary neoplasms of the pancreas (SPN-P) are rare, low-grade malignancies primarily affecting young women. While surgical resection is definitive, the optimal balance between oncological radicality and functional preservation remains a clinical challenge. This study evaluates tailored surgical strategies utilizing minimally invasive and parenchyma-preserving techniques. Patients and Methods: We conducted a multi-institutional retrospective analysis of SPN-P cases treated between March 2020 and May 2023. Out of 167 pancreatic resections, five paradigmatic cases were identified. We analyzed the decision-making process for preoperative staging (CT/MRI/EUS-FNB), surgical approach (open, laparoscopic, or robotic), and the implementation of parenchyma-preserving versus formal resections. Results: The cohort included four females and one male (mean age 40.6 years; range 13–73). Surgical approaches were tailored to tumor location and patient characteristics: two patients underwent pancreatoduodenectomy (one laparotomic, one laparoscopic), two underwent distal pancreatectomy (one robotic, one laparoscopic), and one pediatric patient underwent laparoscopic parenchyma-preserving central pancreatectomy. R0 resection was achieved in all cases. No Grade B/C postoperative pancreatic fistulas (POPF) or complications Clavien-Dindo ≥III occurred. At a mean follow-up (FU) of 38.4 months (range 20–58), the disease-free survival rate was 100%. One patient developed new-onset diabetes mellitus following distal pancreatectomy. Conclusions: A tailored surgical approach—integrating robotic, laparoscopic, and parenchyma-preserving techniques—may enable excellent oncological outcomes while minimizing morbidity. For SPN-P, the choice of procedure should prioritize the preservation of pancreatic function, particularly in young patients, without compromising surgical margins. Full article

Parenchyma-sparing pancreatic surgery (PSPS) is a patient-centered alternative to traditional radical resections for benign and low-grade pancreatic lesions. Unlike pancreaticoduodenectomy and distal pancreatectomy, which tend to cause long-term exocrine and endocrine deficiency, PSPS aims to preserve functional tissue with a guarantee of oncologic safety. Techniques such as enucleation, central pancreatectomy, duodenum-preserving head resection, and uncinectomy are illustrative of this equipoise, with less risk of new-onset diabetes and malabsorption but more short-term morbidity in the form of postoperative pancreatic fistula. Advances in imaging technology, minimally invasive procedures, and robotics technology have extended PSPS indications beyond conventional candidates to thoughtfully selected neuroendocrine tumors, cystic neoplasms, and solid pseudopapillary neoplasms. Results are strongly dependent on patient selection, surgeon experience, and institutional volume, highlighting the importance of centralization and subspecialist training. While oncologic proficiency remains essential in aggressive tumors, evidence is in favor of PSPS being a curative and function-preserving option for properly screened patients with low-grade or benign conditions. Priorities for the future include multicenter prospective trials, optimization of perioperative techniques, and inclusion of patient-reported outcomes. PSPS represents a paradigm shift in pancreatic surgery, where technical innovation is balanced with quality of life in the long term and evolving principles of modern, individualized surgical practice. Full article

Objective: This study aimed to systematically compare the short-term outcomes of minimally invasive pancreatic enucleation (MI-pEn), including laparoscopic and robotic-assisted approaches, and open pancreatic enucleation (O-pEn). Methods: A systematic search of PubMed, MEDLINE, Embase, and Web of Science was conducted for studies published between January 1990 and December 2025 that compared various types of pancreatic enucleation. The literature screening, data extraction, and quality assessment followed the PRISMA guidelines. The meta-analysis was performed using RevMan 5.4.1 and R 4.3.0. Results: Fifteen studies were included, with thirteen comparative studies (463 MI-pEn, 547 O-pEn) incorporated into the meta-analysis. Two studies comparing laparoscopic and robot-assisted enucleation were also included. No significant difference in clinically relevant postoperative pancreatic fistula (CR-POPF) was detected between MI-pEn and O-pEn (OR = 0.78; 95% CI: 0.56–1.07; p = 0.12). However, MI-pEn was associated with significantly reduced operation time (MD = −21.24; p = 0.01), blood loss (MD = −75.88; p < 0.00001), hospital stay (MD = −2.07; p = 0.001), and wound infection (OR = 0.3; p = 0.03). Direct comparisons between robotic and laparoscopic enucleation revealed no significant differences in any outcomes. Conclusions: MI-pEn is safe and feasible and offers advantages in terms of operative time, blood loss, and recovery without increasing complications. Robotic and laparoscopic approaches yield comparable short-term outcomes in pancreatic enucleation, although the potential advantage of robotic surgery in reducing pancreatic fistula risk warrants further validation. 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: Postoperative hemorrhage is a severe complication after pancreatic surgery. While bleeding related to pancreatic fistula is well characterized, hemorrhage secondary to biliary leakage remains poorly understood. This study investigates the incidence, associated factors, clinical course, and outcomes of hepaticojejunostomy insufficiency-associated arterial hemorrhage (HIAA). Methods: This retrospective single-center study included 1413 patients who underwent pancreatic surgery with hepaticojejunostomy between 2004 and 2014. Demographics, underlying disease, surgical procedures, postoperative complications, management strategies, and outcomes were analyzed. Results: HIAA occurred in 13 patients (0.9%), accounting for one third of all erosion-related hemorrhages. The median onset was 16 days postoperatively, and 77% were preceded by sentinel bleeding. Completion pancreatectomy and sepsis were significantly associated with HIAA. The right hepatic artery was the most frequent bleeding source. Primary interventional angiography achieved hemostasis in 62.5% of patients, while 61.5% required surgical revision. Thirty- and ninety-day mortality rates were 15.4% and 30.8%, respectively, compared with 2.1% and 3.7% in the overall cohort. Conclusions: HIAA is a rare but highly lethal complication after pancreatic surgery. It represents a distinct clinical entity characterized by delayed onset, frequent sentinel bleeding, an association with sepsis and completion pancreatectomy, and markedly increased mortality. Early recognition, prompt imaging, and an interventional-first strategy are essential to improve outcomes. Full article

Background: Pancreaticopleural fistula is a rare complication of chronic pancreatitis resulting from pancreatic duct disruption, typically presenting with pleural effusion and predominant respiratory symptoms. Bilateral pleural involvement is exceptionally uncommon and poses significant diagnostic and therapeutic challenges. Case Presentation: A 56-year-old man with a history of chronic alcohol abuse presented with progressive dyspnea and mild epigastric pain. Imaging revealed bilateral pleural effusions, an atrophic pancreas with a markedly dilated main pancreatic duct containing calculi, and a fistulous tract extending from the pancreatic body through the esophageal hiatus into the mediastinum. Magnetic resonance cholangiopancreatography confirmed the diagnosis of chronic calculous pancreatitis complicated by a pancreaticopleural fistula. After unsuccessful conservative management, the patient underwent distal pancreatectomy, resection of the fistulous tract, and Roux-en-Y pancreatojejunostomy. The postoperative course was uneventful, with complete resolution of pleural effusions and sustained clinical improvement. Conclusions: This case highlights the importance of considering pancreaticopleural fistula in patients with unexplained pleural effusions and minimal abdominal symptoms, particularly in the context of chronic pancreatitis. Bilateral involvement, although rare, should not preclude timely diagnosis. Appropriate diagnostic studies by computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography are crucial for establishing the diagnosis. Surgical management offers definitive treatment in patients with ductal obstruction and calculous disease, resulting in excellent long- term outcomes. Full article

Background/Objectives: The International Study Group for Pancreatic Surgery has recently defined post-pancreatectomy acute pancreatitis (PPAP), stating that sustained postoperative hyperamylasemia (POH) for at least 48 h is a pivotal criterion. However, the clinical relevance of POH and PPAP following distal pancreatectomy remains uncertain. This study compares two PPAP definitions differing in POH criteria. Methods: We retrospectively analyzed all patients who consecutively underwent distal pancreatectomy at our institution (2010–2023). PPAP diagnosis required clinical symptoms, characteristic CT findings, and either sustained POH ≥ 48 h (standard group) or transient POH less than 48 h (modified group). Outcomes were compared between definitions. Results: Among 207 patients included, in the standard group, PPAP was diagnosed in 12 (5.8%), and in the modified group in 27 (13.0%) patients. Independent of the applied POH criteria, PPAP was associated with the occurrence of clinically relevant postoperative pancreatic fistulas (standard: 66.7% vs. 23.7%; p < 0.001; modified: 44.4% vs. 23.7%; p = 0.027). Post-pancreatectomy hemorrhage and major complications (Clavien–Dindo grade ≥ III) were also significantly more frequent in patients with PPAP. This was mirrored by a significantly longer length of stay and higher costs. However, in the standard group, PPAP more often resulted in pancreas-specific and major complications compared to the modified group. Of note, in the standard group, only 50% of patients with POH progressed to PPAP, and one-third of patients suffering from PPAP did not develop harmful sequelae. Conclusions: PPAP is an uncommon, however clinically relevant complication following distal pancreatectomy that is better captured using the standard POH definition. Still, further stratification is needed to aid in the prediction of the clinical course. Full article

Background: Postoperative pancreatic fistula (POPF) is a major source of morbidity following a pancreatoduodenectomy (PD), often delaying or precluding adjuvant chemotherapy and potentially compromising long-term oncologic outcomes. While established risk models focus on anatomical and biochemical factors, the role of biliary microbiota remains underexplored. This study aimed to assess relationship between bacteriobilia and the incidence of POPF, as well as its impact on overall survival (OS) in patients undergoing a PD for pancreatic ductal adenocarcinoma (PDAC). Methods: We analyzed the medical histories of 725 patients with a pancreatic tumor who were qualified for surgery between 2017 and 2022. This retrospective cohort study included 138 patients who underwent a PD for histologically confirmed PDAC. Intraoperative bile cultures were obtained and analyzed for microbial presence and resistance patterns. Results: Bacteriobilia was detected in 76.8% of patients, including bacteria with resistance mechanisms (BRM) present in 12.3% of bile samples. Bacterial bile colonization conferred an increased odds of POPF grade B (OR 5.11; p = 0.088), whereas BRM were strongly predisposed to POPF grade C (OR 4.97; p = 0.026). Upon a multivariate analysis, bacteriobilia independently drove clinically relevant POPF and POPF grade B (OR 5.50; p = 0.034 and OR 8.04; p = 0.048, respectively), while BRM remained a key determinant of POPF grade C (OR 6.17; p = 0.047). Beyond morbidity, bile colonization markedly impaired overall survival irrespective of tumor stage (26.7 vs. 54.7 months; log-rank p = 0.009). Conclusions: Bacterial bile colonization may contribute not only to higher rates of POPF but to a significantly reduced OS in patients undergoing a PD for PDAC. Bacteriobilia should be considered as a prognostic factor for worse survival after a PD. Full article

Pancreatic surgery is a technically demanding field associated with frequent morbidity, with pancreatic fistula representing the dominant driver of major complications in pancreaticoduodenectomy (PD). Although refinements in operative technique, perioperative management, and institutional systems have contributed to incremental improvements, the overall incidence of clinically relevant complications has remained largely unchanged over recent decades. This narrative review provides a comprehensive overview of current strategies aimed at reducing morbidity and mortality after pancreaticoduodenectomy, focusing on modifiable technical, pharmacological, nutritional, and systems-based interventions, whilst acknowledging the underlying biological determinants that remain difficult to alter. This review synthesises contemporary evidence on fistula risk modelling, anastomotic reconstruction, and adjunctive operative techniques. The role of pharmacological interventions is examined alongside an evaluation of perioperative nutritional optimisation and enhanced recovery frameworks. Systems-based strategies such as centralisation, failure-to-rescue performance, protocolised pathways, and algorithm-driven postoperative surveillance are highlighted as emerging areas with substantial potential to impact survival independently of complication rates. Finally, this review explores future directions, including radiomics-based risk stratification, intraoperative imaging, and tailored postoperative care. Together, these domains provide a platform for reducing complication severity, standardising postoperative care, and ultimately improving patient outcomes. By integrating these perspectives, this review aims to present a comprehensive and in-depth narrative of how to reduce complications in pancreas surgery. Overall, this narrative review proposes that meaningful improvements in outcomes after PD likely do not arise from the elimination of complications altogether, but rather from improved prediction, prevention where possible, and critically, more effective systems of care that reduce the severity and consequences of complications when they occur. Full article

Background/Objectives: To evaluate short-term postoperative outcomes in octogenarians undergoing robotic pancreaticoduodenectomy. Methods: In compliance with the PRISMA statement standards, a systematic review and random-effects meta-analysis was conducted. All studies reporting short-term postoperative outcomes in patients aged ≥ 80 undergoing robotic pancreaticoduodenectomy were included and analyzed. Results: A total of 321 octogenarians from five studies were included. The mean operative time was 459.7 min (95% CI 398.6–520.8) and the estimated intraoperative blood loss was 216.1 mL (95% CI 147.4–284.8). Conversion to open occurred in 3.8% (95% CI 0.0–7.7). The risk of postoperative mortality was 4.5% (95% CI 1.7–7.2) and Clavien-Dindo grade ≥ III (major) complications occurred in 28.0% (95% CI 22.9–33.1). The risk of grade B or C postoperative pancreatic fistula was 10% (95% CI 6.5–13.5). The hospital stay was 14.9 days (95% CI 10.2–19.5). The risk of reoperation and readmission were 8.0% (95% CI 4.4–11.7) and 25.6% (95% CI 16.9–34.3), respectively. Compared to patients aged <80, the risk of major complications was higher (OR: 1.81, p = 0.010) and hospital stay was longer (MD: 5.19 days, p = 0.030) in octogenarians. Compared to the open approach, robotic approach was associated with longer operative time (MD: 137.08 min, p = 0.0009), less intraoperative blood loss (MD: −246.00 mL, p = 0.010), and lower major complications (OR: 0.62, p = 0.020). Conclusions: Subject to selection and confounding bias, robotic pancreaticoduodenectomy may be safe with acceptable postoperative mortality and morbidity in highly selected octogenarians with good performance status. The results of the current study can be used for hypothesis synthesis and power analysis in future comparative studies. Full article

Background: Postoperative pancreatic fistula remains a frequent complication after distal pancreatectomy and represents the first cause for major morbidity and mortality. Multiple strategies have been proposed to mitigate the severity of pancreatic fistula, but their real benefits remain inconclusive. This study aimed to identify effective mitigation strategies for clinically relevant pancreatic fistula (CR-POPF) through a systematic review of randomized clinical trials. Methods: A systematic search of the Medline and Web of Science databases was conducted for studies published between 2006 and February 2025. Eligible studies included randomized clinical trials evaluating strategies to mitigate clinically relevant postoperative pancreatic fistula following distal pancreatectomy. Only studies in English and involving human subjects were included. Results: Twenty-seven studies were found eligible, comprising 4062 patients, treated with 22 different strategies classified in 8 categories: tissue coverage, sealants and glues, systemic corticoids, analogues of somatostatin, anastomosis of the stump, drain usage, closure of the stump and transpapillary stent. Only 6 studies demonstrated a significant reduction in CR-POPF, strategies applied include systemic corticoids, selective use of drains, polyglycolic acid mesh, reinforced staplers, and collagen enhanced thrombin sealant. Conclusions: Studies reporting successful strategies show considerable heterogeneity in both the included populations and the way the strategies were applied. A personalized approach based on the risk of developing fistula and specific pancreatic features may be beneficial and should be further explored in future randomized clinical trials. Full article

Introduction: Minimally invasive pancreatoduodenectomy (MIPD), including laparoscopic (LPD) and robotic approaches (RPD), has gained increasing attention as an alternative to open pancreatoduodenectomy (OPD). Despite rapid technological progress, concerns persist regarding safety, reproducibility, and oncological adequacy. The publication of randomized controlled trials (RCTs) provides essential high-level evidence to reassess the true benefits and limitations of MIPD. Methods: This narrative review synthesizes all available RCTs comparing LPD and RPD with OPD. Major domains evaluated include mortality, major morbidity, intraoperative parameters, postoperative recovery, oncological outcomes, conversion, costs, and the influence of surgeon experience and institutional volume. The objective is to contextualize RCT findings rather than perform a quantitative meta-analysis. Discussion: Across studies, LPD demonstrates comparable mortality and complication rates to OPD in high-volume centers, with consistent reductions intraoperative blood loss (IBL) and shorter recovery or length of stay (LOS). RPD shows more heterogeneous results: one large trial reported improved postoperative recovery, whereas the EUROPA trial identified higher rates of pancreatic fistula (POPF) and delayed gastric emptying (DGE) alongside significantly increased costs. Both LPD and RPD achieve oncological outcomes equivalent to OPD, and 3-year survival data confirm the long-term non-inferiority of LPD. However, operative time remains longer for all minimally invasive approaches, and conversion persists as a marker of technical difficulty and incomplete learning curve. Conclusions: Current RCT evidence indicates that MIPD is safe, feasible, and oncologically sound only when performed by surgeons who have surpassed the demanding learning curve within specialized, high-volume centers. The benefits, mainly reduced IBL and faster recovery, must be weighed against longer operative times, conversion risks, and substantially higher costs for RPD. MIPD should therefore be considered an advanced option rather than a universal standard, and its broader implementation requires structured training pathways, appropriate patient selection, and institutional readiness. Full article