Background: s/Aims: To evaluate the impact of unplanned conversion to open surgery on resection margin status and postoperative complications in patients undergoing minimally-invasive resection of colorectal liver metastases (CRLM). Methods: This study performed a proportion meta-analysis and meta-regression using random-effects modelling in accordance with PRISMA guidelines. Studies with at least 15 patients that reported conversion to open surgery in individuals receiving minimally-invasive CRLM resection were included. The association of unplanned conversion with postoperative outcomes was analyzed. Results: Eighty-six studies encompassing 18,138 patients were analyzed. The overall conversion rate was 5.8% (95% CI 5%–6.6%).Conversion was associated with improved R0 resection rates (coefficient: 2.167, p < 0.001) but was also linked to increased postoperative mortality (coefficient: 7.585, p = 0.001) and morbidity (coefficient: 1.737, p = 0.003); there was no significant impact on 5-year overall survival (coefficient: 0.700, p = 0.989) or 5-year disease-free survival (coefficient: –72.900, p = 0.157). Specifically, conversion due to oncological concern was associated with higher rates of R0 resection (coefficient: 0.638, p = 0.005); conversion resulting from iatrogenic injuries was associated with lower R0 resection rates (coefficient: –1.478, p < 0.001); conversion for technical difficulties was associated with lower postoperative morbidity (coefficient: –0.380, p = 0.006). Conclusions Unplanned conversion to open may carry prognostic and oncological implications for minimally-invasive resection of CRLM. Although conversion due to bleeding and iatrogenic injury is routinely considered, conversion prompted by technical difficulties or oncological concerns should not be considered failure, as it may be associated with improved patient outcomes.

Background: s/Aims: To determine short-term and long-term outcomes after pancreas preserving total duodenectomy (PPTD). Methods: A case series and a complementary meta-analysis were conducted. All patients with (pre)neoplastic lesions of duodenum who underwent PPTD in a tertiary center for pancreatic surgery between May 2009 and October 2022 were included for the case series.All studies in the literature with a sample size of 10 or more patients reporting outcomes of PPTD were included for the meta-analysis. Results: A total of 439 patients (18 from case series and 421 from literature) were analyzed. Clavien-Dindo (CD) I complications in 2.9% (95% confidence interval [CI] 0.6%–5.2%), CD II complications in 21.1% (14.6%–27.6%), CD III complications in 18.1% (9.3%–26.9%), CD IV complications in 2.7% (0.5%–4.9%), and CD V complications in 2.2% (0.2%–4.2%) of patients were found. Probabilities of overall survival and recurrence-free survival at 15 years were 87% and 86%, respectively. There was no significant difference in the risk of mortality (odds ratio [OR]: 0.82, p = 0.830), total complications (OR: 0.77, p = 0.440), postoperative pancreatic fistula (OR: 0.43, p = 0.140), delayed gastric emptying (OR: 0.70, p = 0.450), or postoperative bleeding (OR: 0.97, p = 0.960) between PPTD and pancreaticoduodenectomy. Conclusions PPTD is safe and feasible for (pre)neoplastic lesions of duodenum not involving the pancreatic head. The risk of severe complications (CD > III) is low and long-term outcomes are favorable. Whether PPTD provides advantages over more radical techniques in terms of long-term outcomes remains controversial and requires further research.

To examine the feasibility and safety of robotic radical resection (RRR) for hilar cholangiocarcinoma (HCCA). A PRISMA-compliant meta-analysis with meta-regression was conducted, including studies reporting outcomes of RRR in patients with HCCA. Six studies comprising 295 patients were included. In highly selected patients (body mass index [BMI] < 25 kg/m” ; tumor size < 3 cm), RRR of HCCA proved safe and feasible (Clavien-Dindo ≥ III complications: 14.8% [95% confidence interval 8.7%–20.8%]; 30-day mortality:1.9% [0%–4.2%]; conversion to open surgery: 1.9% [0%–4.2%]; intraoperative blood loss: 210 mL [119–301 mL]; operative time: 481 minutes [339–623 minutes]; R0 resection rate: 82.2% [75.0%–89.4%]; retrieved lymph nodes: 12 [9–16]). Younger age (p = 0.008), higher BMI (p = 0.009), larger tumors (p = 0.048), and performing liver resections (p = 0.017) increased blood loss. American Society of Anesthesiologists status ≥ III (p < 0.001) and Bismuth IV disease (p < 0.001) increased operative times. Preoperative biliary drainage (p = 0.027) enhanced R0 resection rates. RRR led to less bleeding (mean difference [MD]: –184 mL, p = 0.0005), longer operative times (MD:162 minutes, p = 0.001), and improved R0 resection rates (odds ratio: 3.29, p = 0.006) compared with the open approach. Subject to selection bias and type 2 error, RRR for HCCA might be safe and feasible in highly selected patients (favorable BMI and tumor size). The findings should not be taken as definitive conclusions but may be used for hypothesis generation in subsequent trials.

Background: s/Aims: To determine short-term and long-term outcomes after pancreas preserving total duodenectomy (PPTD). Methods: A case series and a complementary meta-analysis were conducted. All patients with (pre)neoplastic lesions of duodenum who underwent PPTD in a tertiary center for pancreatic surgery between May 2009 and October 2022 were included for the case series.All studies in the literature with a sample size of 10 or more patients reporting outcomes of PPTD were included for the meta-analysis. Results: A total of 439 patients (18 from case series and 421 from literature) were analyzed. Clavien-Dindo (CD) I complications in 2.9% (95% confidence interval [CI] 0.6%–5.2%), CD II complications in 21.1% (14.6%–27.6%), CD III complications in 18.1% (9.3%–26.9%), CD IV complications in 2.7% (0.5%–4.9%), and CD V complications in 2.2% (0.2%–4.2%) of patients were found. Probabilities of overall survival and recurrence-free survival at 15 years were 87% and 86%, respectively. There was no significant difference in the risk of mortality (odds ratio [OR]: 0.82, p = 0.830), total complications (OR: 0.77, p = 0.440), postoperative pancreatic fistula (OR: 0.43, p = 0.140), delayed gastric emptying (OR: 0.70, p = 0.450), or postoperative bleeding (OR: 0.97, p = 0.960) between PPTD and pancreaticoduodenectomy. Conclusions PPTD is safe and feasible for (pre)neoplastic lesions of duodenum not involving the pancreatic head. The risk of severe complications (CD > III) is low and long-term outcomes are favorable. Whether PPTD provides advantages over more radical techniques in terms of long-term outcomes remains controversial and requires further research.

To examine the feasibility and safety of robotic radical resection (RRR) for hilar cholangiocarcinoma (HCCA). A PRISMA-compliant meta-analysis with meta-regression was conducted, including studies reporting outcomes of RRR in patients with HCCA. Six studies comprising 295 patients were included. In highly selected patients (body mass index [BMI] < 25 kg/m” ; tumor size < 3 cm), RRR of HCCA proved safe and feasible (Clavien-Dindo ≥ III complications: 14.8% [95% confidence interval 8.7%–20.8%]; 30-day mortality:1.9% [0%–4.2%]; conversion to open surgery: 1.9% [0%–4.2%]; intraoperative blood loss: 210 mL [119–301 mL]; operative time: 481 minutes [339–623 minutes]; R0 resection rate: 82.2% [75.0%–89.4%]; retrieved lymph nodes: 12 [9–16]). Younger age (p = 0.008), higher BMI (p = 0.009), larger tumors (p = 0.048), and performing liver resections (p = 0.017) increased blood loss. American Society of Anesthesiologists status ≥ III (p < 0.001) and Bismuth IV disease (p < 0.001) increased operative times. Preoperative biliary drainage (p = 0.027) enhanced R0 resection rates. RRR led to less bleeding (mean difference [MD]: –184 mL, p = 0.0005), longer operative times (MD:162 minutes, p = 0.001), and improved R0 resection rates (odds ratio: 3.29, p = 0.006) compared with the open approach. Subject to selection bias and type 2 error, RRR for HCCA might be safe and feasible in highly selected patients (favorable BMI and tumor size). The findings should not be taken as definitive conclusions but may be used for hypothesis generation in subsequent trials.

Background: s/Aims: To determine short-term and long-term outcomes after pancreas preserving total duodenectomy (PPTD). Methods: A case series and a complementary meta-analysis were conducted. All patients with (pre)neoplastic lesions of duodenum who underwent PPTD in a tertiary center for pancreatic surgery between May 2009 and October 2022 were included for the case series.All studies in the literature with a sample size of 10 or more patients reporting outcomes of PPTD were included for the meta-analysis. Results: A total of 439 patients (18 from case series and 421 from literature) were analyzed. Clavien-Dindo (CD) I complications in 2.9% (95% confidence interval [CI] 0.6%–5.2%), CD II complications in 21.1% (14.6%–27.6%), CD III complications in 18.1% (9.3%–26.9%), CD IV complications in 2.7% (0.5%–4.9%), and CD V complications in 2.2% (0.2%–4.2%) of patients were found. Probabilities of overall survival and recurrence-free survival at 15 years were 87% and 86%, respectively. There was no significant difference in the risk of mortality (odds ratio [OR]: 0.82, p = 0.830), total complications (OR: 0.77, p = 0.440), postoperative pancreatic fistula (OR: 0.43, p = 0.140), delayed gastric emptying (OR: 0.70, p = 0.450), or postoperative bleeding (OR: 0.97, p = 0.960) between PPTD and pancreaticoduodenectomy. Conclusions PPTD is safe and feasible for (pre)neoplastic lesions of duodenum not involving the pancreatic head. The risk of severe complications (CD > III) is low and long-term outcomes are favorable. Whether PPTD provides advantages over more radical techniques in terms of long-term outcomes remains controversial and requires further research.

To examine the feasibility and safety of robotic radical resection (RRR) for hilar cholangiocarcinoma (HCCA). A PRISMA-compliant meta-analysis with meta-regression was conducted, including studies reporting outcomes of RRR in patients with HCCA. Six studies comprising 295 patients were included. In highly selected patients (body mass index [BMI] < 25 kg/m” ; tumor size < 3 cm), RRR of HCCA proved safe and feasible (Clavien-Dindo ≥ III complications: 14.8% [95% confidence interval 8.7%–20.8%]; 30-day mortality:1.9% [0%–4.2%]; conversion to open surgery: 1.9% [0%–4.2%]; intraoperative blood loss: 210 mL [119–301 mL]; operative time: 481 minutes [339–623 minutes]; R0 resection rate: 82.2% [75.0%–89.4%]; retrieved lymph nodes: 12 [9–16]). Younger age (p = 0.008), higher BMI (p = 0.009), larger tumors (p = 0.048), and performing liver resections (p = 0.017) increased blood loss. American Society of Anesthesiologists status ≥ III (p < 0.001) and Bismuth IV disease (p < 0.001) increased operative times. Preoperative biliary drainage (p = 0.027) enhanced R0 resection rates. RRR led to less bleeding (mean difference [MD]: –184 mL, p = 0.0005), longer operative times (MD:162 minutes, p = 0.001), and improved R0 resection rates (odds ratio: 3.29, p = 0.006) compared with the open approach. Subject to selection bias and type 2 error, RRR for HCCA might be safe and feasible in highly selected patients (favorable BMI and tumor size). The findings should not be taken as definitive conclusions but may be used for hypothesis generation in subsequent trials.

The role of surgical resection in patients with recurrent pancreatic cancer is unclear. We aimed to evaluate the survival outcomes of pancreatic re-resection for locally recurrent pancreatic cancer following index pancreatectomy. A literature search was carried out in CENTRAL, EMBASE, MEDLINE, CINAHL, and Web of Science. Proportion meta-analysis model was constructed to quantify 1 to 5-year survival after pancreatic re-resection for locally recurrent pancreatic cancer. Random-effects modelling was applied to calculate pooled outcome data. Fifteen retrospective studies were included, reporting a total of 250 patients who underwent pancreatic re-resection for locally recurrent pancreatic cancer following their index pancreatectomy. Pancreatic re-resection was associated with 1-year survival 70.6% (95% confidence interval [CI], 65.0−76.2), 2-year survival 38.8% (95% CI, 28.6−49.0), 3-year survival 20.2% (95% CI, 13.8−26.7), and 5-year survival 9.2% (95% CI, 5.5−12.8). The between-study heterogeneity was insignificant in all outcome syntheses.Repeat pancreatectomy for local recurrence of pancreatic cancer in the remnant pancreas following the index pancreatectomy is associated with acceptable overall patient survival. We recommend selective re-resection of such recurrences in younger patients with favorable tumor size and location. Our findings may encourage more robust studies to be conducted in this context to provide stronger evidence.

This study aimed to compare outcomes of hand-sewn and stapler closure techniques of pancreatic stump in patients undergoing distal pancreatectomy (DP). Impact of stapler closure reinforcement using mesh on outcomes was also evaluated. Literature search was carried out using multiple data sources to identify studies that compared hand-sewn and stapler closure techniques in management of pancreatic stump following DP. Odds ratio (OR) was determined for clinically relevant postoperative pancreatic fistula (POPF) via random-effects modelling. Subsequently, trial sequential analysis was performed. Thirty-two studies with a total of 4,022 patients undergoing DP with hand-sewn (n = 1,184) or stapler (n = 2,838) closure technique of pancreatic stump were analyzed. Hand-sewn closure significantly increased the risk of clinically relevant POPF compared to stapler closure (OR: 1.56, p = 0.02). When stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.54, p = 0.002). When only randomized controlled trials were considered, there was no significant difference in clinically relevant POPF between hand-sewn and stapler closure techniques (OR: 1.20, p = 0.64) or between reinforced and standard stapler closure techniques (OR: 0.50, p = 0.08). When observational studies were considered, hand-sewn closure was associated with a significantly higher rate of clinically relevant POPF compared to stapler closure (OR: 1.59, p = 0.03). Moreover, when stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.55, p = 0.02). Trial sequential analysis detected risk of type 2 error. In conclusion, reinforced stapler closure in DP may reduce risk of clinically relevant POPF compared to hand-sewn closure or stapler closure without reinforcement.Future randomized research is needed to provide stronger evidence.

To compare the outcomes of low central venous pressure (CVP) to standard CVP during laparoscopic liver resection. The study design was a systematic review following the PRISMA statement standards. The available literature was searched to identify all studies comparing low CVP with standard CVP in patients undergoing laparoscopic liver resection. The outcomes included intraoperative blood loss (primary outcome), need for blood transfusion, mean arterial pressure, operative time, Pringle time, and total complications. Random-effects modelling was applied for analyses. Type I and type II errors were assessed by trial sequential analysis (TSA). A total of 8 studies including 682 patients were included (low CVP group, 342; standard CVP group, 340). Low CVP reduced intraoperative blood loss during laparoscopic liver resection (mean difference [MD], –193.49 mL; 95% confidence interval [CI], –339.86 to –47.12; p = 0.01).However, low CVP did not have any effect on blood transfusion requirement (odds ratio [OR], 0.54; 95% CI, 0.28–1.03; p = 0.06), mean arterial pressure (MD, –1.55 mm Hg; 95% CI, –3.85–0.75; p = 0.19), Pringle time (MD, –0.99 minutes; 95% CI, –5.82–3.84; p = 0.69), operative time (MD, –16.38 minutes; 95% CI, –36.68–3.39; p = 0.11), or total complications (OR, 1.92; 95% CI, 0.97–3.80; p = 0.06). TSA suggested that the meta-analysis for the primary outcome was not subject to type I or II errors. Low CVP may reduce intraoperative blood loss during laparoscopic liver resection (moderate certainty); however, this may not translate into shorter operative time, shorter Pringle time, or less need for blood transfusion. Randomized controlled trials with larger sample sizes will provide more robust evidence.