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The increasing use of neoadjuvant chemotherapy based on the fluorouracil plus leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) regimens to downstage borderline and locally advanced pancreatic tumors has led to a renewed interest in extended pancreatectomies.1–4 The policy to propose resection for pancreatic adenocarcinomas invading the splenomesentericoportal venous axis only after having observed stability or response after induction chemotherapy seems to be increasingly adopted. 1,4–8 While histological venous invasion represents a poor prognostic factor,6,9 short- term outcomes of pancreatectomies with venous resection are comparable to standard resection in high-volume centers. 6,10 Adjuvant chemotherapy after resection seems to be beneficial in patients having poor prognostic factors on pathology. 7 Extensive agreement on indications and oncological management for patients with borderline tumors exists, but approaches and techniques for venous resection still differ across centers. 6,11–16 The International Study Group for Pancreatic Surgery has uniformly defined the extent of venous resection in 2014. In case of segmental venous resection (types 3 and 4), both direct anastomoses and autologous/heterologous pros- thesis have been described. 12 The choice of reconstruction type seems to be mostly related to the personal experience of the surgeons. Some authors have discouraged the use of prosthesis because of the theoretical increase in the risk of thrombosis and infection, especially in presence of digestive reconstruction.17 Others have reported favorable outcomes using prosthetic and/or vascular tube interposition for venous reconstruction.14,18 Reconstruction of the mesentericoportal venous axis re- mains a challenging procedure and must be planned pre- operatively to reduce the rate of non-curative resection 19 and avoid vascular complications.

Background We systematically reviewed the literature on definitions and outcomes of large-for-size (LFS) syndrome in orthotopic liver transplantation (LT). Methods This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Cochrane Library, PubMed, and Embase were searched (January 1990–January 2019) for studies reporting LFS in LT. Primary outcomes were definitions and mortality of LFS LT. Results Eleven studies reporting patients with LFS LT were identified. Four different formulas (graft-to-recipient weight ratio (GRWR), body surface area index (BSAi), donor standardized total liver volume (sTLV)–to–recipient sTLV ratio, and graft weight/right anteroposterior distance (RAP) ratio) with their critical thresholds were found. There were 81 patients (54% women) with a median weight and height of 62.5 kg (range, 40–105 kg) and 165 cm (range, 145–180 cm). The median graft weight was 1772 g (range, 1290–2400 g), and the median GWRW was 2.77% (range, 2.1–4.00%). Graft venous outflow obstruction was described in seven patients (8.6%). At the time of LT, fascial closure was not achieved in 24 patients (29.6%) and the graft size was reduced by a liver resection in three patients (3.7%). Thirteen deaths (16%) were reported in the first 90 postoperative days with two patients undergoing re-transplant. Conclusions LFS LT remains heterogeneously defined but characterized by high mortality rates despite the use of tailored surgical solutions (graft reduction and open abdomen). A composite definition is proposed in order to better describe LFS clinical syndrome.

Background Use of robotic surgery has gained increasing acceptance over the last few years. There are few reports, however, on advanced pancreatic robotic surgery. In fact, the indication for robotic surgery in pancreatic disease has been controversial. This paper retrospectively reviews one surgeon’s experience with robotic surgery to treat pancreatic disease, and analyzes its indications and outcomes, as well as the controversy that exists. Methods A retrospective review of the charts of all patients who underwent robotic surgery for pancreatic disease by a single surgeon at two different institutions was carried out. Results From October 2000 to January 2009, 134 patients underwent robotic-assisted surgery for different pancreatic pathologies. All procedures were performed using the da Vinci robotic system. Of the 134 patients, 83 were female. The average age of all patients was 57 years (range 24–86 years). Mean operating room (OR) time was 331 min (75–660 min). There were 14 conversions to open surgery. Mean length of stay was 9.3 days (3–85 days). Length of stay for patients with no complications was 7.9 days (3–15 days). The postoperative morbidity rate was 26% and the mortality rate was 2.23% (three patients). Among the procedures performed were 60 pancreaticoduodenectomies, 23 spleen-preserving distal pancreatectomies, 23 splenopancreatectomies, 3 middle pancreatectomies, 1 total pancreatectomy, and 3 enucleations. Another 21 patients underwent different surgical procedures for treatment of acute and chronic pancreatitis. Two cases of pancreaticoduodenectomy were performed in outside institutions and are not included in this series. Conclusions This is the largest series of robotic pancreatic surgery presented to date. Robotic surgery enables difficult technical maneuvers to be performed that facilitate the success of pancreatic minimally invasive surgery. The results in this series demonstrate that it is feasible and safe. Complication and mortality rates are comparable to those of open surgery but with the advantages of minimally invasive surgery.

The efficacy of FOLFIRINOX chemotherapy gave renewed interest for surgery in case of locally advanced pancreatic ductal adenocarcinoma. Consistent series of pancreatectomy with arterial and venous resection have been reported recently and that described acceptable short and long-term outcomes in selected patients operated by high volume institutions by dedicated surgical team. In a didactical video we showed our approach for resecting a locally advanced pancreatic ductal adenocarcinoma involving both the splenomesentericoportal venous confluence and a replaced common hepatic artery arising from the superior mesenteric artery (SMA). A large dorsal pancreatic artery arising from the SMA is used for the arterial reconstruction in this particular case. The approach used entails extensive bowel mobilization, mesenteric approach to the coelio-mesenteric vessels and arterial divestment making feasible arterial and venous resection with reconstruction without graft interposition.

Background Minimally invasive pancreaticoduodenectomy (PD) remains one of the most challenging abdominal procedures, and its application is poorly reported in the literature so far. To date, few data are available comparing a minimally invasive approach to open PD. The aim of the present study is to compare the robotic and open approaches for PD at a single institution. Methods Data from 83 consecutive PD procedures performed between January 2002 and May 2010 at a single institution were retrospectively reviewed. Patients were stratified into two groups: the open group ( n  = 39; 47%) and the robotic group ( n  = 44; 53%). Results Patients in the robotic group were statistically older (63 years of age versus 56 years; p  = 0.04) and heavier (body mass index: 27.7 vs. 24.8; p  = 0.01); and had a higher American Society of Anesthesiologists (ASA) score (2.5 vs. 2.15; p  = 0.01) when compared to the open group. Indications for surgery were the same in both groups. The robotic group had a significantly shorter operative time (444 vs. 559 min; p  = 0.0001), reduced blood loss (387 vs. 827 ml; p  = 0.0001), and a higher number of lymph nodes harvested (16.8 vs. 11; p  = 0.02) compared to the open group. There was no significant difference between the two groups in terms of complication rates, mortality rates, and hospital stay. Conclusions The authors present one of the first studies comparing open and robotic PD. While it is too early to draw definitive conclusions concerning the long-term outcomes, short-term results show a positive trend in favor of the robotic approach without compromising the oncological principles associated with the open approach.

Recurrence after resection of intrahepatic cholangiocarcinoma (ICC) remains common. The present study sought to evaluate risk factors for recurrence and the results of repeat liver resection (RLR) for recurrent ICC. Between 1997 and 2012, clinical data and outcomes of 125 consecutive patients undergoing liver resection for ICC were retrospectively analyzed. The rate of R0 resection was 89% (n = 110). Overall median survival was 35 months, and 1-, 3-, and 5-year actuarial survival rates were 80%, 48%, and 28%, respectively. Recurrence occurred in 76 patients (63.5%) and was intrahepatic only for 39 patients (51%). Tumor size greater than 5 cm was identified as an independent risk factor for recurrence (P ≤ .0001). RLR for recurrent ICC was feasible in 10 patients (25%) with a median survival after recurrence of 25 months (16 to 76). Tumor size more than 5 cm represents an independent risk factor for recurrence after resection of ICC. RLR in case of recurrent ICC, when feasible, is associated with longer overall survival. •Recurrence after resection of intrahepatic cholangiocarcinoma (ICC) is common.•Recent studies showed that cure after resection of ICC seems to be an elusive goal.•Tumor size greater than 5 cm is an independent risk factor for recurrence.•Recurrence after resection of ICC is often beyond the limits of resectability.•A repeat liver resection (RLR) was feasible in only 25% of patients.•A RLR was associated with prolonged overall survival.

Background The best surgical approach to treat synchronous colorectal liver metastases (CRLM) remains unclear. Here, we aimed to identify prognostic factors associated with limited survival comparing patients undergoing primary-first resection (PF) and simultaneous resection (SR) approaches. Methods We retrospectively reviewed clinical data of 217 patients who underwent resection for synchronous CRLMs between January 1, 2011, and December 31, 2021. There were 133 (61.2%) PF resection and 84 (38.8%) SRS. The two groups of patients were compared using propensity score matching (PSM) analysis and cox analysis was performed to identify prognostic factors for overall survival (OS). Results After PSM, two groups of 71 patients were compared. Patients undergoing SR had longer operative time (324 ± 104 min vs 250 ± 101 min; p  < 0.0001), similar transfusion (33.3% vs 28.1%; p  = 0.57), and similar complication rates (35.9% vs 27.2%; p  = 0.34) than patients undergoing PF. The median overall survival and 5-year survival rates were comparable ( p  = 0.94) between patients undergoing PF (48.2 months and 44%) and patients undergoing SR (45.9 months and 30%). Multivariate Cox analysis identified pre-resection elevated CEA levels (HR: 2.38; 95% CI: 1.20–4.70; P  = .01), left colonic tumors (HR: 0.34; 95% CI: 0.17–0.68; P  = .002), and adjuvant treatment (HR: 0.43; 95% CI: 0.22–0.83; P  = .01) as independent prognostic factors for OS. Conclusions In the presence of synchronous CRLM, right colonic tumors, persistent high CEA levels before surgery, and the absence of adjuvant treatment identified patients characterized by a limited survival rate after resection. The approach used (PF vs SR) does not influence short and long-term outcomes.

Obesity is a challenging condition for pancreatic surgery, and some authors recommend delaying pancreatic resection for non‐malignant pancreatic tumors in obese patients. We present a case of a 45‐year‐old woman with a body mass index (BMI) of 56 who was surgically treated in our department for a mucinous cystadenoma discovered during preoperative work‐up for bariatric surgery. To decrease the risk involved in pancreatic surgery, a glucagon‐like peptide‐1 receptor agonist was administered for 6 months, which led to a weight loss of 20 kg and a BMI of 48 at the time of surgery. A laparoscopic left splenopancreatectomy was performed within 7 months of the diagnosis. The postoperative length of stay was 19 days. Pathology confirmed that the tumor was mucinous cystadenoma with mild dysplasia. As of 17 months later, the patient is doing well and has lost an additional 10 kg.