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BackgroundPancreatic enucleation (PE) is a viable option for the removal of non-malignant pancreatic masses leading to complete preservation of organ function. Nevertheless, PE is associated with substantial rates of post-operative pancreatic fistula (POPF), particularly when the mass is close to the main pancreatic duct (MPD). Preoperative stenting of the MPD may prevent its injury when performing PE. This paper describes a novel technique of “deep” PE preceded by endoscopic stenting of the MPD.MethodsFrom January 2017 to May 2019, patients with small pancreatic neuroendocrine tumors proximal to the MPD were candidates for PE with previous stenting of the MPD at the University of Verona, Italy, and at the UCLA Medical Center, Los Angeles, California. The endoscopic stenting was scheduled either the day before or 3 weeks before surgery, depending on the participating institute.ResultsTen patients were included in this pilot study. The endoscopic procedure was successful and well tolerated in all cases. Open, laparoscopic and robotic PE were performed. Seven patients had surgical complications. Among these, six developed a post-operative pancreatic fistula (POPF), but neither grade C fistulas nor disruptions of the MPD were detected. At pathology, a low grade pancreatic neuroendocrine tumor was confirmed in all cases.ConclusionIn the setting of high-volume centers, this procedure is safe, and it is associated with acceptable short-term surgical morbidity. The preoperative stenting of the MPD might extend the surgical indications for PE.

BackgroundThe pancreatic transection method during distal pancreatectomy is thought to influence postoperative fistula rates. Yet, the optimal technique for minimizing fistula occurrence is still unclear. The present randomized controlled trial compared stapled versus ultrasonic transection in elective distal pancreatectomy.MethodsPatients undergoing distal pancreatectomy from July 2018 to July 2020 at two high-volume institutions were considered for inclusion. Exclusion criteria were contiguous organ resection and a parenchymal thickness > 17 mm on intraoperative ultrasound. Eligible patients were randomized in a 1:1 ratio to stapled transection (Endo GIA Reinforced Reload with Tri-Staple Technology®) or ultrasonic transection (Harmonic Focus® + or Harmonic Ace® + shears). The primary endpoint was postoperative pancreatic fistula. Secondary endpoints included overall complications, abdominal collections, and length of hospital stay.ResultsOverall, 72 patients were randomized in the stapled transection arm and 73 patients in the ultrasonic transection arm. Postoperative pancreatic fistula occurred in 23 patients (16%), with a comparable incidence between groups (12% in stapled transection versus 19% in ultrasonic dissection arm, p = 0.191). Overall complications did not differ substantially (35% in stapled transection versus 44% in ultrasonic transection arm, p = 0.170). There was an increased incidence of abdominal collections in the ultrasonic dissection group (32% versus 14%, p = 0.009), yet the need for percutaneous drain did not differ between randomization arms (p = 0.169). The median length of stay was 8 days in both groups (p = 0.880). Intraoperative blood transfusion was the only factor independently associated with postoperative pancreatic fistula on logistic regression analysis (OR 4.8, 95% CI 1.2–20.0, p = 0.032).ConclusionThe present randomized controlled trial of stapled versus ultrasonic transection in elective distal pancreatectomy demonstrated no significant difference in postoperative pancreatic fistula rates and no substantial clinical impact on other secondary endpoints.

Background To compare the postoperative course of elderly patients (≥70 years) submitted to minimally invasive (MIDP) versus open distal pancreatectomy (ODP) and to evaluate if the modified Frailty Index (mFI) predicts the surgical course of elderly patients submitted to DP. Methods Data of patients aged ≥70 who underwent DP at a single institution between March 2011 and December 2019 were retrospectively retrieved. A 2:1 propensity score matching (PSM) was used to correct for differences in baseline characteristics. Then, postoperative complications were compared between the two groups (MIDP vs. ODP). Additionally, the entire cohort of DP elderly patients was stratified according to the mFI into three groups: non-frail (mFI = 0), mildly frail (mFI = 1/2), or severely frail (mFI = 3) and then compared. Results A total of 204 patients were analyzed. After PSM, 40 MIDP and 80 ODP patients were identified. The complications considered stratified homogenously between the two groups, with no statistically significant differences. The severity of the postoperative course increased as mFI did among the three groups regarding any complication ( p  = 0.022), abdominal collection ( p  = 0.014), pulmonary complication ( p  = 0.001), postoperative confusion ( p  = 0.047), Clavien-Dindo severity ≥3 events ( p  = 0.036), and length of stay ( p  = 0.018). Conclusions Elderly patients can be safely submitted to MIDP. The mFI identifies frail elderly patients more prone to develop surgical and non-surgical complications after DP.

Pancreatic ductal adenocarcinoma (PDAC) has still a dismal prognosis. Locally advanced pancreatic cancer (LAPC) accounts for the 40% of the new diagnoses. Current treatment options are based on chemo- and radiotherapy regimens. Local ablative techniques seem to be the future therapeutic option for stage-III patients with PDAC. Radiofrequency Ablation (RFA) and Irreversible Electroporation (IRE) are actually the most emerging local ablative techniques used on LAPC. Initial clinical studies on the use of these techniques have already demonstrated encouraging results in terms of safety and feasibility. Unfortunately, few studies on their efficacy are currently available. Even though some reports on the overall survival are encouraging, randomized studies are still required to corroborate these findings. This study provides an up-to-date overview and a thematic summary of the current available evidence on the application of RFA and IRE on PDAC, together with a comparison of the two procedures.

Background: One of the challenges in treating pancreatic ductal adenocarcinoma (PDAC) with stereotactic radiotherapy (SRT) is to manage lesions abutted to the duodenum, bowel and stomach. Simultaneous integrated protection (SIP) is one of the proposed approaches to increase plan reproducibility and quality. However, no clinical data are available regarding the dosimetric objectives impacting local control probability. Methods: This is a prospective, single-arm study. Key inclusion criteria were as follows: PDAC histology; tumor abutment with duodenum, stomach, or small bowel; and SRT schedule consisting of 45 Gy in six fractions. Delineation of the PTV overlapped with critical OARs (PTV_SIP) and PTV outside critical OARs (PTV_Dominant) was mandatory. Dose constraints were as follows: (near) maximum dose, D2cc, and D20cc to critical OARs 38 Gy, 32 Gy, and 24 Gy, respectively. This study was designed to prospectively investigate the main clinical and dosimetric parameters impacting freedom from local recurrence (FFLR). Results: From June 2019 to January 2024, 104 patients were enrolled. One-year FFLR was 91.7%. Fifteen events of local failure occurred (17.6%). Mapping of local relapses showed a relapse inside the PTV_SIP area in nine patients and outside the PTV_SIP in six cases (NS). Whole PTV > 69 cc, PTV_SIP > 4 cc, PTV-SIP/whole PTV ratio > 7%, (near) Dmin to PTV_SIP < 25 Gy, mean dose to PTV_SIP < 28 Gy, and (near) Dmin to PTV_Dominant < 29 Gy were associated with worse FFLR. Multivariable analysis showed PTV_SIP absolute volume of more than 4 cc, mean dose to PTV_SIP < 28 Gy and whole PTV > 69 cc were independently related to worse FFLR. One case of acute G4 toxicity and two cases of acute G3 toxicity occurred, with two late toxicity deaths not certainly due to treatment. Conclusions: In this prospective study, SIP planning strategy with six fractions is safe and effective in pancreatic targets with critical contact with critical OARs. Given its potential advantages, SIP planning is a potential innovative strategy that should be compared to standard SRT planning in an ad hoc trial design.

Portal annular pancreas (PAP) is a pancreatic congenital anomaly consisting of pancreatic parenchyma encircling the portal vein and/or the superior mesenteric vein. It has been reported that the risk of developing a post-operative pancreatic fistula is higher following pancreaticoduodenectomy in patients with PAP, probably because of the possibility of leaving undrained a portion of pancreatic parenchyma during the reconstructive phase. Few manuscripts have reported a surgical technique of pancreaticoduodenectomy in case of PAP, herein we report the first case of a patient with PAP undergoing laparoscopic pancreaticoduodenectomy.

Background. For Tis and T1a gallbladder cancer (GbC), laparoscopic cholecystectomy can provide similar survival outcomes compared to open cholecystectomy. However, for patients affected by resectable T1b or more advanced GbC, open approach radical cholecystectomy (RC), consisting in gallbladder liver bed resection or segment 4b-5 bisegmentectomy, with locoregional lymphadenectomy, is considered the gold standard while minimally invasive RC (MiRC) is skeptically considered. Aim. To analyze current literature on perioperative and oncologic outcomes of MiRC for patients affected by GbC. Methods. A Medline review of published articles until June 2016 concerning MiRC for GbC was performed. Results. Data relevant for this review were presented in 13 articles, including 152 patients undergoing an attempt of MiRC for GbC. No randomized clinical trial was found. The approach was laparoscopic in 147 patients and robotic in five. Conversion was required in 15 (10%) patients. Postoperative complications rate was 10% with no mortality. Long-term survival outcomes were reported by 11 studies, two of them showing similar oncologic results when comparing MiRC with matched open RC. Conclusions. Although randomized clinical trials are still lacking and only descriptive studies reporting on limited number of patients are available, current literature seems suggesting that when performed at highly specialized centers, MiRC for GbC is safe and feasible and has oncologic outcomes comparable to open RC.

BackgroundMinimally invasive spleen-preserving distal pancreatectomy (SPDP) has emerged as a parenchyma-preserving approach and has become the standard treatment for pancreatic benign and low-grade malignant lesions. Nevertheless, minimally invasive SPDP is still technically challenging, especially when vessel preservation is intended. This study aims to describe the technique and outcomes of laparoscopic (LSPDP) and robot-assisted spleen-preserving distal pancreatectomy (RSPDP) with intended vessel preservation, highlighting the important tips and tricks to overcome technical obstacles and optimize surgical outcomes.MethodsA retrospective observational study of consecutive patients undergoing LSPDP and RSPDP with intended vessel preservation by a single surgeon in two different centers. A video demonstrating both surgical techniques is attached.ResultsA total of 50 patients who underwent minimally invasive SPDP were included of which 88% underwent LSPDP and 12% RSPDP. Splenic vessels were preserved in 37 patients (74%) while a salvage vessel-resecting technique was performed in 13 patients (26%). The average surgery time was 178 ± 74 min for the vessel-preserving and 188 ± 57 for the vessel-resecting technique (p = 0.706) with an estimated blood loss of 100 mL in both groups (p = 0.663). The overall complication rate was 46% (n = 23) with major complications (Clavien Dindo ≥ III) observed in 14% (n = 7) of the patients. No conversions occurred. The median length of hospital stay was 4 days.ConclusionThis study presented the results after minimally invasive SPDP with intended vessel preservation by a highly experienced pancreatic surgeon. It provided tips and tricks to successfully accomplish a minimally invasive SPDP, which can contribute to quick patient rehabilitation and optimal postoperative results.

BackgroundThis study analyzed the Quality of Life (QoL) and cost-effectiveness of laparoscopic (LDP) versus robotic distal pancreatectomy (RDP).MethodsConsecutive patients submitted to LDP or RDP from 2010 to 2020 in four high-volume Italian centers were included, with a minimum of 12 months of postoperative follow-up were included. QoL was evaluated using the EORTC QLQ-C30 and EQ-5D questionnaires, self-reported by patients. After a propensity score matching, which included BMI, gender, operation time, multiorgan and vascular resections, splenic preservation, and pancreatic stump management, the mean differential cost and Quality-Adjusted Life Years (QALY) were calculated and plotted on a cost-utility plane.ResultsThe study population consisted of 564 patients. Among these, 271 (49%) patients were submitted to LDP, while 293 (51%) patients to RDP. After propensity score matching, the study population was composed of 159 patients in each group, with a median follow-up of 59 months. As regards the QoL analysis, global health and emotional functioning domains showed better results in the RDP group (p = 0.037 and p = 0.026, respectively), whereas the other did not differ. As expected, the median crude costs analysis confirmed that RDP was more expensive than LDP (16,041 Euros vs. 10,335 Euros, p < 0.001). However, the robotic approach had a higher probability of being more cost-effective than the laparoscopic procedure when a willingness to pay more than 5697 Euros/QALY was accepted.ConclusionRDP was associated with better QoL as explored by specific domains. Crude costs were higher for RDP, and the cost-effectiveness threshold was set at 5697 euros/QALY.

BackgroundThis study aimed to discuss and report the trend, outcomes, and learning curve effect after minimally invasive distal pancreatectomy (MIDP) at two high-volume centres.MethodsPatients undergoing MIDP between January 1999 and December 2018 were retrospectively identified from prospectively maintained electronic databases. The entire cohort was divided into two groups constituting the “early” and “recent” phases. The learning curve effect was analyzed for laparoscopic (LDP) and robotic distal pancreatectomy (RDP). The follow-up was at least 2 years.ResultsThe study population included 401 consecutive patients (LDP n = 300, RDP n = 101). Twelve surgeons performed MIDP during the study period. Although patients were more carefully selected in the early phase, in terms of median age (49 vs. 55 years, p = 0.026), ASA class higher than 2 (3% vs. 9%, p = 0.018), previous abdominal surgery (10% vs. 34%, p < 0.001), and pancreatic adenocarcinoma (PDAC) (7% vs. 15%, p = 0.017), the recent phase had similar perioperative outcomes. The increase of experience in LDP was inversely associated with the operative time (240 vs 210 min, p < 0.001), morbidity rate (56.5% vs. 40.1%, p = 0.005), intra-abdominal collection (28.3% vs. 17.3%, p = 0.023), and length of stay (8 vs. 7 days, p = 0.009). Median survival in the PDAC subgroup was 53 months.ConclusionIn the setting of high-volume centres, the surgical training of MIDP is associated with acceptable rates of morbidity. The learning curve can be largely achieved by several team members, improving outcomes over time. Whenever possible resection of PDAC guarantees adequate oncological results and survival.