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.

To compare the procedural outcomes of minimally invasive and open central pancreatectomy. A systematic review in compliance with PRISMA statement standards was conducted to identify and analyze studies comparing the procedural outcomes of minimally invasive (laparoscopic or robotic) central pancreatectomy with the open approach. Random effects modeling using intention to treat data, and individual patient as unit of analysis, was used for analyses. Seven comparative studies including 289 patients were included. The two groups were comparable in terms of baseline characteristics. The minimally invasive approach was associated with less intraoperative blood loss (mean difference [MD]: −153.13 mL, p = 0.0004); however, this did not translate into less need for blood transfusion (odds ratio [OR]: 0.30, p = 0.06). The minimally invasive approach resulted in less grade B−C postoperative pancreatic fistula (OR: 0.54, p = 0.03); this did not remain consistent through sensitivity analyses. There was no difference between the two approaches in operative time (MD: 60.17 minutes, p = 0.31), Clavien–Dindo ≥ 3 complications (OR: 1.11, p = 0.78), postoperative mortality (risk difference:−0.00, p = 0.81), and length of stay in hospital (MD: −3.77 days, p = 0.08). Minimally invasive central pancreatectomy may be as safe as the open approach; however, whether it confers advantage over the open approach remains the subject of debate. Type 2 error is a possibility, hence adequately powered studies are required for definite conclusions; future studies may use our data for power analysis.

To compare the procedural outcomes of minimally invasive and open central pancreatectomy. A systematic review in compliance with PRISMA statement standards was conducted to identify and analyze studies comparing the procedural outcomes of minimally invasive (laparoscopic or robotic) central pancreatectomy with the open approach. Random effects modeling using intention to treat data, and individual patient as unit of analysis, was used for analyses. Seven comparative studies including 289 patients were included. The two groups were comparable in terms of baseline characteristics. The minimally invasive approach was associated with less intraoperative blood loss (mean difference [MD]: −153.13 mL, p = 0.0004); however, this did not translate into less need for blood transfusion (odds ratio [OR]: 0.30, p = 0.06). The minimally invasive approach resulted in less grade B−C postoperative pancreatic fistula (OR: 0.54, p = 0.03); this did not remain consistent through sensitivity analyses. There was no difference between the two approaches in operative time (MD: 60.17 minutes, p = 0.31), Clavien–Dindo ≥ 3 complications (OR: 1.11, p = 0.78), postoperative mortality (risk difference:−0.00, p = 0.81), and length of stay in hospital (MD: −3.77 days, p = 0.08). Minimally invasive central pancreatectomy may be as safe as the open approach; however, whether it confers advantage over the open approach remains the subject of debate. Type 2 error is a possibility, hence adequately powered studies are required for definite conclusions; future studies may use our data for power analysis.

To compare the procedural outcomes of minimally invasive and open central pancreatectomy. A systematic review in compliance with PRISMA statement standards was conducted to identify and analyze studies comparing the procedural outcomes of minimally invasive (laparoscopic or robotic) central pancreatectomy with the open approach. Random effects modeling using intention to treat data, and individual patient as unit of analysis, was used for analyses. Seven comparative studies including 289 patients were included. The two groups were comparable in terms of baseline characteristics. The minimally invasive approach was associated with less intraoperative blood loss (mean difference [MD]: −153.13 mL, p = 0.0004); however, this did not translate into less need for blood transfusion (odds ratio [OR]: 0.30, p = 0.06). The minimally invasive approach resulted in less grade B−C postoperative pancreatic fistula (OR: 0.54, p = 0.03); this did not remain consistent through sensitivity analyses. There was no difference between the two approaches in operative time (MD: 60.17 minutes, p = 0.31), Clavien–Dindo ≥ 3 complications (OR: 1.11, p = 0.78), postoperative mortality (risk difference:−0.00, p = 0.81), and length of stay in hospital (MD: −3.77 days, p = 0.08). Minimally invasive central pancreatectomy may be as safe as the open approach; however, whether it confers advantage over the open approach remains the subject of debate. Type 2 error is a possibility, hence adequately powered studies are required for definite conclusions; future studies may use our data for power analysis.