Background: s/Aims: Pancreatic texture is difficult to predict without palpation. Soft pancreatic texture is associated with increased post-operative complications, including postoperative pancreatic fistula (POPF), cardiac, and respiratory complications. We aimed to develop a calculator predicting pancreatic texture using patient factors and to illustrate complications from soft pancreatic texture following pancreaticoduodenectomy. Methods: Data was collected from the 2016 to 2021 American College of Surgeons National Surgical Quality Improvement database including 17,706 pancreaticoduodenectomy cases. Patients were categorized into two cohorts based on pancreatic texture (9,686 hard, 8,020 soft). Multivariable modeling assessed the impact of patient factors on complications, mortality, and pancreatic texture. These preoperative factors were integrated into a risk calculator (preoperative soft pancreas risk score [PSPRS]) that predicts pancreatic texture. Results: Patients with a soft pancreas had higher rates of postoperative complications compared to those with a hard pancreas (56.5% vs 42.2%; p < 0.001), particularly a threefold increase in POPF rate, and at least a twofold increase in rates of acute kidney injury, deep organ space infection, septic shock, and prolonged length of stay. Female sex (odds ratio [OR]: 1.14, confidence interval [CI]: 1.06–1.22, p < 0.001) and higher body mass index (OR: 1.12, CI: 1.09–1.16, p < 0.001) were independently associated with a soft pancreas. PSPRS ≥6 correctly identified >40% of patients preoperatively as having a hard pancreas (68.9% specificity). Conclusions A soft pancreas was independently associated with serious postoperative complications. Our results were integrated into a risk calculator predicting pancreatic texture from preoperative patient factors, potentially enhancing preoperative counseling and surgical decision-making.

Solid pseudopapillary neoplasms (SPNs) are uncommon pancreatic tumors that primarily affect young females. We report a case of a 24-year-old female diagnosed with SPN and liver metastasis during a routine examination. Imaging revealed an 8-cm pancreatic mass with multiple liver metastases. Histopathology confirmed SPN. Subsequent next-generation sequencing revealed a CTNNB1 mutation.The patient underwent a total pancreatectomy with splenectomy, right hemihepatectomy, and intraoperative radiofrequency ablation.Two years after the surgery, she remained complication-free. She is under regular surveillance. This case underscores the importance of early detection and comprehensive management of SPN.

Background: s/Aims: Irreversible electroporation (IRE) may have a potential application as either a “back-up therapy” or for margin accentuation during trial dissection of locally advanced pancreatic cancer (LAPC). The aim of this report was to describe our experience with IRE in terms of its potential applications mentioned above. Methods: A clinical policy to use IRE in LAPC patients undergoing exploratory surgery after neoadjuvant therapy (NAT) was initiated in 2017. If resection was feasible, IRE was used for margin accentuation. If not, then IRE was undertaken as a “back-up therapy” of non-resectable tumor. Data on baseline characteristics, perioperative 90-day morbidity, recurrence-free survival (RFS) and overall survival (OS) were collected. Results: IRE was successfully performed in 18 (95%) patients. IRE was abandoned in one case for technical reasons. Nine patients who were found to have an unresectable disease underwent IRE as a “back-up therapy” while the remaining patients received IRE for margin accentuation. Complications were recorded in 33% patients. There was no procedure-related mortality. In the group receiving IRE for margin accentuation, the median RFS was 10.0 months (range, 4.5–15.0 months). The median OS of our cohort was 22 months (range, 14.75–27.50 months). Conclusions This report shows that in patients with LAPC undergoing exploratory surgery following NAT, IRE seems technically feasible for margin accentuation or as a “back-up therapy”. More data are needed to determine procedure-related morbidity, mortality, and any effects of IRE on cancer-related survival.

Laparoscopic total pancreatectomy (LTP) is technically challenging and infrequently documented in the literature. In this paper, we present a new approach for performing fully LTP, a pancreatic tail-first approach with a counterclockwise technique, to accomplish total mesopancreas dissection and standard lymphadenectomy en bloc. Firstly, the tail and body of the pancreas without the spleen were dissected retrogradely, starting from the lower border of the body of pancreas and then from left to right. After that, a counterclockwise dissection of the tail and body of the pancreas was performed. The splenic artery and vein were divided at the terminal end of the pancreatic tail. The spleen was preserved. The entire body and tail of the pancreas were then pulled to the right side. This maneuver facilitated the isolation and dissection of arteries in the retropancreatic region more easily via laparoscopy, including the splenic artery, gastroduodenal artery, and supporting superior mesenteric artery first-approach. It also enabled total mesopancreas dissection.The inferior pancreaticoduodenal artery was resected last during this phase. The remainder of the dissection was like that of a laparoscopic pancreaticoduodenectomy with total mesopancreas dissection, involving two laparoscopic manual anastomoses. The operative time was 490 minutes and the total blood loss was 100 mL. Pathology revealed a low-grade intraductal papillary mucinous neoplasm extending from the head to the tail of the pancreas.

Background: s/Aims: Liver transplantation (LT) is now a critical, life-saving treatment for patients with liver cirrhosis or hepatocellular carcinoma. Despite its significant benefits, biliary complications (BCs) continue to be a major cause of postoperative morbidity.This study evaluates the fluorescence intensity (FI) of the common bile duct (CBD) utilizing near-infrared indocyanine green (ICG) imaging, and examines its association with the incidence of BCs within three months post-LT. Methods: This investigation analyzed data from nine living donor LT (LDLT) recipients who were administered 0.05 mg/kg of ICG prior to bile duct anastomosis. Real-time perfusion of the CBD was recorded for three minutes using an ICG camera, and FI was quantified using Image J (National Institutes of Health). Key parameters assessed included F max, F1/2 max, T1/2 max, and the slope (F max/ T max) to evaluate the fluorescence response. Results: BCs occurred in two out of nine patients. These two patients exhibited the longest T1/2 max values, which were linked with lower slope values, implicating a potential relationship between extended T1/2 max, reduced slope, and the occurrence of postoperative BCs. Conclusions The study indicates that ICG fluorescence imaging may serve as an effective tool for assessing bile duct perfusion in LDLT patients. While the data suggest that an extended T1/2 max and lower slope may correlate with an increased risk of BCs, further validation through larger studies is required to confirm the predictive value of ICG fluorescence imaging in this setting.

Background: s/Aims: In recent years, many minimally invasive techniques have been introduced to reduce the number of ports in laparoscopic cholecystectomy (LC), offering benefits such as reduced postoperative pain and improved cosmetic outcomes. ArtiSential®is a new multi-degree-of-freedom articulating laparoscopic instrument that incorporates the ergonomic features of robotic surgery, potentially overcoming the spatial limitations of laparoscopic surgery. ArtiSential® LC can be performed using only two ports. This study aims to compare the surgical outcomes of ArtiSential® LC with those of single-fulcrum LC. Methods: This retrospective study compared ArtiSential® LC and single-fulcrum LC among LCs performed for gallbladder (GB) stones at the same center, analyzing the basic characteristics of patients; intraoperative outcomes, such as operative time, estimated blood loss, and intraoperative GB rupture; and postoperative outcomes, such as length of hospital stay, incidence of postoperative complications, and postoperative pain. Results: A total of 88 and 63 patients underwent ArtiSential® LC and single-fulcrum LC for GB stones, respectively. Analysis showed that ArtiSential® LC resulted in significantly fewer cases of surgeries longer than 60 minutes (30 vs. 35 min, p = 0.009) and intraoperative GB ruptures (2 vs. 10, p = 0.007). In terms of postoperative outcomes, ArtiSential® LC showed better results in the respective visual analog scale (VAS) scores immediately after surgery (2.59 vs. 3.73, p < 0.001), and before discharge (1.44 vs. 2.02, p = 0.01). Conclusions ArtiSential® LC showed better results in terms of surgical outcomes, especially postoperative pain. Thus, ArtiSential®LC is considered the better option for patients, compared to single-fulcrum LC.

Laparoscopic cholecystectomy (LC) is the gold standard for the treatment of symptomatic gallstones, acute cholecystitis, and acute gallstone pancreatitis. In recent years, the development and diffusion of robotic surgery have provided surgeons with the opportunity to apply this innovative approach to cholecystectomy, yielding interesting results. However, as with any new surgical technique, robotic cholecystectomy (RC) has met with skepticism within the surgical community. Beyond the understandable concerns regarding increased costs, some authors have claimed that RC is associated with a higher complication rate compared to LC. We reviewed the existing literature on this subject, discussing the limitations and strengths of the most significant publications and critically analyzing them. The analysis of the literature indicates that RC is safe and effective, with no definitive evidence of its inferiority compared to LC. Some of the published papers are of low quality and biased, even with significant sample sizes. Furthermore, we believe that comparing an established technique like LC with a new and not yet standardized one such as RC is somewhat illogical. RC represents a significant advance in minimally invasive surgery and should be viewed as an opportunity to familiarize oneself with the robotic device and to enhance the surgeon’s skills in preparation for more complex robotic operations. The robotic approach can be beneficial in selected cases of cholecystectomy where fine dissection is required. With further reductions in costs, RC could become the future gold standard for benign gallbladder disorders.

Background: s/Aims: Given the high mortality associated with gallbladder cancer (GBC), the efficacy of adjuvant therapy (AT) remains controversial. We audited our data over an 11-year period to assess the impact of AT. Methods: This study included all patients who underwent curative resection for GBC from 2007 to 2017. Analyses were conducted of clinicopathological characteristics, surgical details, and postoperative therapeutic records. The benefits of adjuvant chemotherapy (CT) or chemoradiotherapy (CTRT) were evaluated against surgery alone using SPSS version 20 for statistical analysis. Results: The median age of patients (n = 142) was 50 years. The median overall survival (OS) was 93, 34, and 30 months with CT, CTRT, and surgery alone respectively (p = 0.612). Multivariate analysis indicated that only disease stage and microscopically involved margins significantly impacted OS and disease-free survival (DFS). CT showed increased effectiveness across all prognostic subsets, except for stage 4 and margin-positive resections. Following propensity score matching, median DFS and OS were higher in the CT group than in the CTRT group, although the differences were not statistically significant (p > 0.05). Conclusions Radically resected GBC patients appear to benefit more from adjuvant CT, while CTRT should be reserved for cases with high-risk features.

Robotic liver transplantation represents a cutting-edge technique that may surpass traditional open surgery. Nonetheless, it introduces unique anesthetic challenges, including extended pneumoperitoneum, restricted patient access, and a risk of undetected blood loss. This article describes an anesthetic approach and patient outcomes for the first four total robotic liver transplants performed at a tertiary university hospital in Portugal, along with inaugural procedures of their kind in Europe. We retrospectively analyzed surgical and anesthetic data from four patients who underwent total robotic liver transplantation from February to April 2024. Data encompassed clinical profile, preoperative assessment, surgical and anesthesia details, postoperative course, and outcomes. Patients’ age ranged from 51 to 69 years. Their cirrhosis was primarily due to alcohol use, hepatitis C virus infection, hepatocellular carcinoma, or nonalcoholic steatohepatitis. General anesthesia was administered. Hemodynamic monitoring and goal-directed fluid therapy were conducted using a PiCCO system. Blood loss varied from 1,000 to 5,000 mL. Blood products were transfused as needed. All donor livers underwent hypothermic oxygenated machine perfusion before transplantation. After surgery, two patients were immediately extubated, while two required extended ventilation. Hospital stays ranged from 10 to 40 days. The 30-day survival rate was 100%. This initial case series affirmed the feasibility and safety of total robotic liver transplantation for carefully selected patients, yielding favorable short-term results. Anesthetic management can rely on proactive strategies, acute situational awareness, and effective multidisciplinary collaboration.