Pub Date : 2026-01-22DOI: 10.1097/sla.0000000000007017
Amir M Parray,Niket Shah,Sohan Lal Solanki,Vandana Agarwal,Nitin Sudhakar Shetty,Suyash Kulkarni,Manish S Bhandare,Vikram Chaudhari,Shailesh V Shrikhande
OBJECTIVETo evaluate the T-MOD PD (Timing-Mechanism-Opportunity-Disease) framework for classifying mortality after pancreatoduodenectomy (PD), focusing on preventability and rescue opportunities.BACKGROUNDPancreatoduodenectomy mortality (2-10%) is reported as binary endpoints, obscuring distinctions between surgery-related and systemic causes and limiting targeted quality improvement.METHODSRetrospective analysis of 1,727 consecutive PDs (2014-2024) at a high-volume centre. All 58 deaths (3.4%) were independently adjudicated across four axes: Timing (T1-T3), Mechanism (M1-M3), Opportunity (O1-O4), and Disease (D1-D3). Deaths were categorized as surgery-attributable potentially preventable (SAPM), surgery-attributable non-preventable (SANPM), or non-surgery-attributable mortality (NSAM).RESULTSStriking phenotypic clustering emerged: 38% of deaths (22/58) converged in T1M1O1D1 (early, surgery-related, strategically modifiable, resectable disease), with 19% (11/58) in T2M1O1D1. Together, these postoperative pancreatic fistula (POPF)-driven phenotypes accounted for 57% of mortality. Domain analysis revealed 66% early deaths (T1), 74% surgery-related mechanisms (M1), and critically, 72% potentially modifiable opportunities (O1: 72%; O2: 22%; O3: 2%; O4: 3%). Overall, 74% were classified as SAPM. Timeline reconstruction identified median 72-hour delays in recognition and escalation despite warning signs at postoperative day 5-6, with 22-day median interval from clinically relevant POPF diagnosis to death, suggesting 35-40% preventability in the dominant phenotype. Perfect interobserver agreement was achieved (κ=1.0).CONCLUSIONST-MOD PD provides reproducible mortality phenotyping revealing 72% of deaths are potentially modifiable, with dominant phenotypes sharing POPF pathways and identifiable rescue delays, enabling phenotype-specific quality improvement.
{"title":"Beyond Binary Mortality Endpoints: The T-MOD PD Framework (Timing-Mechanism-Opportunity-Disease) for Phenotype-Specific Root Cause Analysis of Mortality after Pancreatoduodenectomy A Retrospective Observational Cohort Study.","authors":"Amir M Parray,Niket Shah,Sohan Lal Solanki,Vandana Agarwal,Nitin Sudhakar Shetty,Suyash Kulkarni,Manish S Bhandare,Vikram Chaudhari,Shailesh V Shrikhande","doi":"10.1097/sla.0000000000007017","DOIUrl":"https://doi.org/10.1097/sla.0000000000007017","url":null,"abstract":"OBJECTIVETo evaluate the T-MOD PD (Timing-Mechanism-Opportunity-Disease) framework for classifying mortality after pancreatoduodenectomy (PD), focusing on preventability and rescue opportunities.BACKGROUNDPancreatoduodenectomy mortality (2-10%) is reported as binary endpoints, obscuring distinctions between surgery-related and systemic causes and limiting targeted quality improvement.METHODSRetrospective analysis of 1,727 consecutive PDs (2014-2024) at a high-volume centre. All 58 deaths (3.4%) were independently adjudicated across four axes: Timing (T1-T3), Mechanism (M1-M3), Opportunity (O1-O4), and Disease (D1-D3). Deaths were categorized as surgery-attributable potentially preventable (SAPM), surgery-attributable non-preventable (SANPM), or non-surgery-attributable mortality (NSAM).RESULTSStriking phenotypic clustering emerged: 38% of deaths (22/58) converged in T1M1O1D1 (early, surgery-related, strategically modifiable, resectable disease), with 19% (11/58) in T2M1O1D1. Together, these postoperative pancreatic fistula (POPF)-driven phenotypes accounted for 57% of mortality. Domain analysis revealed 66% early deaths (T1), 74% surgery-related mechanisms (M1), and critically, 72% potentially modifiable opportunities (O1: 72%; O2: 22%; O3: 2%; O4: 3%). Overall, 74% were classified as SAPM. Timeline reconstruction identified median 72-hour delays in recognition and escalation despite warning signs at postoperative day 5-6, with 22-day median interval from clinically relevant POPF diagnosis to death, suggesting 35-40% preventability in the dominant phenotype. Perfect interobserver agreement was achieved (κ=1.0).CONCLUSIONST-MOD PD provides reproducible mortality phenotyping revealing 72% of deaths are potentially modifiable, with dominant phenotypes sharing POPF pathways and identifiable rescue delays, enabling phenotype-specific quality improvement.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"64 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2026-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146015417","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-21DOI: 10.1097/sla.0000000000007013
Anagi C Wickremasinghe,Patrick Garduce,Dianne L Brown,Alyssa J Budin,Chiara Chadwick,Yit J Leang,Michael Talbot,Susannah Ahern,Andrew D MacCormick,Ian D Caterson,Wendy A Brown
OBJECTIVETo determine the incidence, timing, type, and indications for revisional surgery (defined as any operation performed after primary MBS up to 10 y).BACKGROUNDUnderstanding long-term reoperation rates is essential for patient counselling and service planning in metabolic bariatric surgery (MBS). While primary MBS is well established as the most effective treatment for severe obesity, revisional procedures are increasingly required due to weight regain, complications or intolerance of the index procedure. However, high-quality population-level data on revision risk after metabolic bariatric surgery is limited.METHODSWe conducted a retrospective cohort study using prospectively collected data from the Australian and New Zealand Bariatric Surgery Registry. Patients undergoing primary MBS on or before December 31, 2023, were followed for up to 10 years. Kaplan-Meier analysis was conducted.RESULTS145,193 patients (median age 42 (IQR 33-50) years 78.7% female) underwent primary MBS. Over a median 5.6 y (IQR 2.9-8.1), 5,681 patients (4%) underwent a first revisional surgery (7.3 per 1,000 person-years; 95% CI, 7.1-7.4). The observed incidence was highest after AGB (28.7%; 46.7% reversals), followed by RYGB (4.8%; 94.8% corrective), OAGB (3.5%; 52.7% corrective) and SG (2.5%; 69.6% conversions). AGB revisions were mostly due to recurrent weight gain (13.3%) and port-related issues (12.7%); reflux was the most common reason after SG (29.1%) and OAGB (27.3%), while strictures were the most frequent indication following RYGB (23.4%).CONCLUSIONSIncidence, type, and indication of revisional procedures differ from those of the primary procedure. These findings may guide patient decision-making and health system planning.
{"title":"Incidence and Indications for Revisional Metabolic Bariatric Surgery: A 10-Year Analysis from the Australian and New Zealand Registry.","authors":"Anagi C Wickremasinghe,Patrick Garduce,Dianne L Brown,Alyssa J Budin,Chiara Chadwick,Yit J Leang,Michael Talbot,Susannah Ahern,Andrew D MacCormick,Ian D Caterson,Wendy A Brown","doi":"10.1097/sla.0000000000007013","DOIUrl":"https://doi.org/10.1097/sla.0000000000007013","url":null,"abstract":"OBJECTIVETo determine the incidence, timing, type, and indications for revisional surgery (defined as any operation performed after primary MBS up to 10 y).BACKGROUNDUnderstanding long-term reoperation rates is essential for patient counselling and service planning in metabolic bariatric surgery (MBS). While primary MBS is well established as the most effective treatment for severe obesity, revisional procedures are increasingly required due to weight regain, complications or intolerance of the index procedure. However, high-quality population-level data on revision risk after metabolic bariatric surgery is limited.METHODSWe conducted a retrospective cohort study using prospectively collected data from the Australian and New Zealand Bariatric Surgery Registry. Patients undergoing primary MBS on or before December 31, 2023, were followed for up to 10 years. Kaplan-Meier analysis was conducted.RESULTS145,193 patients (median age 42 (IQR 33-50) years 78.7% female) underwent primary MBS. Over a median 5.6 y (IQR 2.9-8.1), 5,681 patients (4%) underwent a first revisional surgery (7.3 per 1,000 person-years; 95% CI, 7.1-7.4). The observed incidence was highest after AGB (28.7%; 46.7% reversals), followed by RYGB (4.8%; 94.8% corrective), OAGB (3.5%; 52.7% corrective) and SG (2.5%; 69.6% conversions). AGB revisions were mostly due to recurrent weight gain (13.3%) and port-related issues (12.7%); reflux was the most common reason after SG (29.1%) and OAGB (27.3%), while strictures were the most frequent indication following RYGB (23.4%).CONCLUSIONSIncidence, type, and indication of revisional procedures differ from those of the primary procedure. These findings may guide patient decision-making and health system planning.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"39 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146005326","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
OBJECTIVETo identify prognostic factors, including preoperative treatment duration, among patients who underwent conversion surgery (CS) for unresectable locally advanced pancreatic cancer (UR-LAPC).BACKGROUNDWhile CS has been increasingly adopted for UR-LAPC, optimal perioperative strategies remain controversial.METHODSThis multicenter study included 465 UR-LAPC patients who underwent CS following preoperative chemotherapy with FOLFIRINOX (FFX) or gemcitabine plus nab-paclitaxel (GnP) from 2015 to 2020 at 84 Japanese institutions.RESULTSMedian overall survival (OS) from treatment initiation was 43.8 months with a 5-year survival rate of 37.2%. A prognostic cutoff for preoperative treatment duration was identified at 6.1 months using maximally selected rank statistics. Patients receiving >6 months of preoperative treatment (n=350) demonstrated significantly better OS (50.4 vs. 29.7 mo) and recurrence-free survival (RFS) (15.6 vs. 9.1 mo) compared with those receiving ≤6 months (n=115, both P<0.001). Multivariate analysis identified four independent preoperative prognostic factors: treatment duration >6 months, FFX-based regimens, normal tumor markers (CA19-9 and CEA), and a prognostic nutritional index ≥45 before CS. These four preoperative factors enabled clear prognostic stratification: patients with ≥3 factors showed significantly improved survival compared with those with ≤2 factors (HR 0.44, P<0.0001; 5-year OS: 59.8% vs. 26.3%).CONCLUSIONSThe combination of four preoperative prognostic factors may enable risk stratification among patients undergoing CS for UR-LAPC. These findings may help inform treatment sequencing and patient selection, although external validation is needed to confirm their generalizability.
目的探讨无法切除的局部晚期胰腺癌（UR-LAPC）患者行转化手术（CS）的预后因素，包括术前治疗时间。虽然CS越来越多地用于UR-LAPC，但最佳围手术期策略仍然存在争议。该多中心研究纳入了2015年至2020年84家日本机构的465例UR-LAPC患者，这些患者在术前使用FOLFIRINOX （FFX）或吉西他滨加nab-紫杉醇（GnP）化疗后接受CS。从治疗开始的中位总生存期（OS）为43.8个月，5年生存率为37.2%。术前治疗时间的预后截止时间为6.1个月。与术前治疗≤6个月的患者（n=115，均为P6个月，以ffx为基础的方案，肿瘤标志物（CA19-9和CEA）正常，CS前预后营养指数≥45）相比，接受bbb6个月术前治疗的患者（n=350）表现出更好的OS （50.4 vs 29.7个月）和无复发生存率（RFS） （15.6 vs 9.1个月）。这四个术前因素使预后分层清晰：≥3个因素的患者比≤2个因素的患者生存率显著提高（HR 0.44， P<0.0001； 5年OS: 59.8% vs. 26.3%）。结论术前4个预后因素的结合可对UR-LAPC行CS的患者进行风险分层。这些发现可能有助于告知治疗顺序和患者选择，尽管需要外部验证来确认其普遍性。
{"title":"Clinicopathological Factors on Survival after Conversion Surgery for Unresectable Locally Advanced Pancreatic Cancer: A Nationwide Study by the Japanese Society of Hepato-Biliary-Pancreatic Surgery.","authors":"Satoshi Yasuda,Sohei Satoi,Hideki Takami,Satoshi Hirano,Hirofumi Akita,Yu Takahashi,Yuta Yoshida,Michiaki Unno,Riki Ninomiya,Manabu Kawai,Yuichi Nagakawa,Teiichi Sugiura,Naoto Yamamoto,Minako Nagai,Kenichiro Uemura,Masafumi Imamura,Naoki Ozu,Masafumi Nakamura,Masayuki Otsuka,Masayuki Sho","doi":"10.1097/sla.0000000000007012","DOIUrl":"https://doi.org/10.1097/sla.0000000000007012","url":null,"abstract":"OBJECTIVETo identify prognostic factors, including preoperative treatment duration, among patients who underwent conversion surgery (CS) for unresectable locally advanced pancreatic cancer (UR-LAPC).BACKGROUNDWhile CS has been increasingly adopted for UR-LAPC, optimal perioperative strategies remain controversial.METHODSThis multicenter study included 465 UR-LAPC patients who underwent CS following preoperative chemotherapy with FOLFIRINOX (FFX) or gemcitabine plus nab-paclitaxel (GnP) from 2015 to 2020 at 84 Japanese institutions.RESULTSMedian overall survival (OS) from treatment initiation was 43.8 months with a 5-year survival rate of 37.2%. A prognostic cutoff for preoperative treatment duration was identified at 6.1 months using maximally selected rank statistics. Patients receiving >6 months of preoperative treatment (n=350) demonstrated significantly better OS (50.4 vs. 29.7 mo) and recurrence-free survival (RFS) (15.6 vs. 9.1 mo) compared with those receiving ≤6 months (n=115, both P<0.001). Multivariate analysis identified four independent preoperative prognostic factors: treatment duration >6 months, FFX-based regimens, normal tumor markers (CA19-9 and CEA), and a prognostic nutritional index ≥45 before CS. These four preoperative factors enabled clear prognostic stratification: patients with ≥3 factors showed significantly improved survival compared with those with ≤2 factors (HR 0.44, P<0.0001; 5-year OS: 59.8% vs. 26.3%).CONCLUSIONSThe combination of four preoperative prognostic factors may enable risk stratification among patients undergoing CS for UR-LAPC. These findings may help inform treatment sequencing and patient selection, although external validation is needed to confirm their generalizability.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"63 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146005327","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
OBJECTIVEWe evaluated the impact of normothermic regional perfusion (NRP) on short- and mid-term outcomes of kidney transplantation (KT) using donation after circulatory death (DCD). We further examined the influence of NRP duration and identified subgroups most likely to benefit from its use.BACKGROUNDNRP has recently gained adoption in DCD-KT as a means to mitigate donor warm ischemic injury. However, its effect on graft and patient outcomes particularly beyond one year remains uncertain, and the role of NRP duration and subgroup-specific benefits has not been well defined.METHODSUsing UNOS STAR files, we analyzed 21,010 primary adult DCD-KT cases performed between 2020-2025. Based on prior literature, cases were classified as non-NRP (0-30 min from circulatory death to cross-clamp) or NRP (30-180 min). Propensity score matching (PSM) adjusted for donor and recipient differences. Kaplan-Meier methods assessed graft and patient survival.RESULTSAfter PSM, NRP was associated with reduced DGF (30.3% vs. 49.7%), shorter hospital stay (median 4 vs. 5 d), and improved overall graft and patient survival (P=0.007 and 0.047). No difference was observed in overall graft survival between short and long NRP durations (P=0.62). Subgroup analyses for one-year graft survival revealed that the benefit of NRP was more evident in cases of elderly recipients or donors, high donor BMI, higher KDPI, and prolonged pre-transplant dialysis.CONCLUSIONSNRP improved both short- and mid-term outcomes, including three-year/overall graft/patient survival. NRP duration did not significantly affect overall graft survival. The benefits of NRP were pronounced in high-risk subgroups.
{"title":"Impact of Normothermic Regional Perfusion on Clinical Outcomes in Kidney Transplantation from Donors After Circulatory Death: A US Nationwide Analysis of 38,048 Cases.","authors":"Jiro Kusakabe,Eduardo Fernandes,Khaled Refaai,Ahmed Hussein,Komal Kumar,Aza Abdalla,Shalini Saith,Salwa Rhazouani,Kazunari Sasaki,Neerja Agrawal,Antonio Pinna","doi":"10.1097/sla.0000000000007018","DOIUrl":"https://doi.org/10.1097/sla.0000000000007018","url":null,"abstract":"OBJECTIVEWe evaluated the impact of normothermic regional perfusion (NRP) on short- and mid-term outcomes of kidney transplantation (KT) using donation after circulatory death (DCD). We further examined the influence of NRP duration and identified subgroups most likely to benefit from its use.BACKGROUNDNRP has recently gained adoption in DCD-KT as a means to mitigate donor warm ischemic injury. However, its effect on graft and patient outcomes particularly beyond one year remains uncertain, and the role of NRP duration and subgroup-specific benefits has not been well defined.METHODSUsing UNOS STAR files, we analyzed 21,010 primary adult DCD-KT cases performed between 2020-2025. Based on prior literature, cases were classified as non-NRP (0-30 min from circulatory death to cross-clamp) or NRP (30-180 min). Propensity score matching (PSM) adjusted for donor and recipient differences. Kaplan-Meier methods assessed graft and patient survival.RESULTSAfter PSM, NRP was associated with reduced DGF (30.3% vs. 49.7%), shorter hospital stay (median 4 vs. 5 d), and improved overall graft and patient survival (P=0.007 and 0.047). No difference was observed in overall graft survival between short and long NRP durations (P=0.62). Subgroup analyses for one-year graft survival revealed that the benefit of NRP was more evident in cases of elderly recipients or donors, high donor BMI, higher KDPI, and prolonged pre-transplant dialysis.CONCLUSIONSNRP improved both short- and mid-term outcomes, including three-year/overall graft/patient survival. NRP duration did not significantly affect overall graft survival. The benefits of NRP were pronounced in high-risk subgroups.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"194 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146005324","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-21DOI: 10.1097/sla.0000000000007014
Matthias Pfister,Zhihao Li,Fariba Abbassi,Raphael L C Araujo,Vikram A Chaudhari,Rim Cherif,Laleh Foroutani,Fabio Giannone,Michael Ginesini,Abdallah Iben-Khayat,Boram Lee,Ricardo Nunez,Chie Takishita,Patrick W Underwood,Emanuel Vigia,Elaina Vivian,Yusuke Watanabe,Taiga Wakabayashi,Adnan Alseidi,Fabrizio Di Benedetto,Ugo Boggi,Raffaele Brustia,Tan-To Cheung,Mary E Dillhoff,Brian K P Goh,Ho-Seong Han,Benedetto Ielpo,Jae Hoon Lee,Marcel A Machado,John Martinie,Hugo Pinto Marques,Alejandro Mejia,Yuichi Nagakawa,Masafumi Nakamura,Patrick Pessaux,Patricio M Polanco,Olivier Saint-Marc,Shailesh V Shrikhande,Go Wakabayashi,Pierre-Alain Clavien
OBJECTIVETo establish international benchmark values for relevant outcome parameters in robotic Whipple.SUMMARY BACKGROUND DATAFor safe adoption of surgical innovation, robust quality control is essential. Benchmarking is a validated tool for assessing surgical performance. Recent international consensus identified establishing benchmark values for robotic Whipple as top priority.METHODSWe analyzed consecutive patients undergoing robotic Whipple between 2020-2023 with a minimum one-year follow-up. Reference centers were required to perform ≥15 cases/year, be scientifically active in the field, and maintain a prospective database. Benchmark criteria included benign or resectable malignant disease without neoadjuvant therapy, arterial resection, major co-morbidities, or significant previous abdominal surgery. Benchmarks were established for 13 outcome parameters.RESULTThe benchmark cohort comprised 418 patients from 12 centers across four continents. Benchmark values were: conversion rate ≤4.3%, transfusion rate ≤2.1%, 6-month mortality ≤2.2%, major complications ≤23.2%, and CCI® ≤20.9. Clinically relevant pancreatic fistula (grade B/C) and hemorrhage (grade B/C) rates were ≤23.6% and ≤12.7%, respectively. For pancreatic ductal adenocarcinoma (n=123), the benchmark for lymph node yield was ≥20. Higher surgical difficulty was associated with increased overall postoperative morbidity (R2=0.38, P=0.019), higher center caseload with reduced pancreas-specific complications (R2=0.28, P=0.044). Independent POPF predictors included duct diameter ≤4 mm (OR 1.37, 95% CI: 1.03, 1.82), anticoagulation (OR 2.45, 95% CI: 1.47, 3.99), and indication other than PDAC (OR 2.33, 95% CI: 1.68, 3.27).CONCLUSIONSThis study establishes the first international benchmarks for robotic Whipple, demonstrating oncologic outcomes and morbidity comparable to open surgery with the benefits of minimally invasive surgery.
{"title":"Setting the Standard in Robotic Whipple Surgery: International Multicenter Benchmark Analysis.","authors":"Matthias Pfister,Zhihao Li,Fariba Abbassi,Raphael L C Araujo,Vikram A Chaudhari,Rim Cherif,Laleh Foroutani,Fabio Giannone,Michael Ginesini,Abdallah Iben-Khayat,Boram Lee,Ricardo Nunez,Chie Takishita,Patrick W Underwood,Emanuel Vigia,Elaina Vivian,Yusuke Watanabe,Taiga Wakabayashi,Adnan Alseidi,Fabrizio Di Benedetto,Ugo Boggi,Raffaele Brustia,Tan-To Cheung,Mary E Dillhoff,Brian K P Goh,Ho-Seong Han,Benedetto Ielpo,Jae Hoon Lee,Marcel A Machado,John Martinie,Hugo Pinto Marques,Alejandro Mejia,Yuichi Nagakawa,Masafumi Nakamura,Patrick Pessaux,Patricio M Polanco,Olivier Saint-Marc,Shailesh V Shrikhande,Go Wakabayashi,Pierre-Alain Clavien","doi":"10.1097/sla.0000000000007014","DOIUrl":"https://doi.org/10.1097/sla.0000000000007014","url":null,"abstract":"OBJECTIVETo establish international benchmark values for relevant outcome parameters in robotic Whipple.SUMMARY BACKGROUND DATAFor safe adoption of surgical innovation, robust quality control is essential. Benchmarking is a validated tool for assessing surgical performance. Recent international consensus identified establishing benchmark values for robotic Whipple as top priority.METHODSWe analyzed consecutive patients undergoing robotic Whipple between 2020-2023 with a minimum one-year follow-up. Reference centers were required to perform ≥15 cases/year, be scientifically active in the field, and maintain a prospective database. Benchmark criteria included benign or resectable malignant disease without neoadjuvant therapy, arterial resection, major co-morbidities, or significant previous abdominal surgery. Benchmarks were established for 13 outcome parameters.RESULTThe benchmark cohort comprised 418 patients from 12 centers across four continents. Benchmark values were: conversion rate ≤4.3%, transfusion rate ≤2.1%, 6-month mortality ≤2.2%, major complications ≤23.2%, and CCI® ≤20.9. Clinically relevant pancreatic fistula (grade B/C) and hemorrhage (grade B/C) rates were ≤23.6% and ≤12.7%, respectively. For pancreatic ductal adenocarcinoma (n=123), the benchmark for lymph node yield was ≥20. Higher surgical difficulty was associated with increased overall postoperative morbidity (R2=0.38, P=0.019), higher center caseload with reduced pancreas-specific complications (R2=0.28, P=0.044). Independent POPF predictors included duct diameter ≤4 mm (OR 1.37, 95% CI: 1.03, 1.82), anticoagulation (OR 2.45, 95% CI: 1.47, 3.99), and indication other than PDAC (OR 2.33, 95% CI: 1.68, 3.27).CONCLUSIONSThis study establishes the first international benchmarks for robotic Whipple, demonstrating oncologic outcomes and morbidity comparable to open surgery with the benefits of minimally invasive surgery.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"49 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146005322","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-21DOI: 10.1097/sla.0000000000007016
Jon C Gould
{"title":"GERD Treatment Bias and the Underutilized Fundoplication.","authors":"Jon C Gould","doi":"10.1097/sla.0000000000007016","DOIUrl":"https://doi.org/10.1097/sla.0000000000007016","url":null,"abstract":"","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"1 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146005323","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-21DOI: 10.1097/sla.0000000000007015
Neal E Seymour,Dmitry Nepomnayshy,Melissa N Hanson,Aurora D Pryor,Jacob A Greenberg,Brenessa Lindeman,Karen J Brasel
The "Fundamentals of Laparoscopic Surgery" (FLS) certification has been shown to establish achievement of basic levels of knowledge and skills competencies in laparoscopic surgery by surgical residents. Current evidence shows that this frequently occurs too late in training for residents to use these competencies to facilitate their advancement toward operative autonomy. The American Board of Surgery (ABS) General Surgery Board working with the Society of American Gastrointestinal and Endoscopic Surgeon (SAGES) FLS Committee have jointly formulated a recommendation that FLS certification should ideally be achieved by US surgical residents by the end of postgraduate year-2 in order to facilitate access to more advanced laparoscopic procedures and to achievement of practice readiness.
{"title":"A Recommendation for FLS Certification for General Surgery Residents By the End of the PGY-2 Year.","authors":"Neal E Seymour,Dmitry Nepomnayshy,Melissa N Hanson,Aurora D Pryor,Jacob A Greenberg,Brenessa Lindeman,Karen J Brasel","doi":"10.1097/sla.0000000000007015","DOIUrl":"https://doi.org/10.1097/sla.0000000000007015","url":null,"abstract":"The \"Fundamentals of Laparoscopic Surgery\" (FLS) certification has been shown to establish achievement of basic levels of knowledge and skills competencies in laparoscopic surgery by surgical residents. Current evidence shows that this frequently occurs too late in training for residents to use these competencies to facilitate their advancement toward operative autonomy. The American Board of Surgery (ABS) General Surgery Board working with the Society of American Gastrointestinal and Endoscopic Surgeon (SAGES) FLS Committee have jointly formulated a recommendation that FLS certification should ideally be achieved by US surgical residents by the end of postgraduate year-2 in order to facilitate access to more advanced laparoscopic procedures and to achievement of practice readiness.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"101 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2026-01-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146005325","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-16DOI: 10.1097/sla.0000000000007010
Andrew G Shuman,Anji Wall
{"title":"Revisiting Organ Donor Choice in the Circulatory Death Era.","authors":"Andrew G Shuman,Anji Wall","doi":"10.1097/sla.0000000000007010","DOIUrl":"https://doi.org/10.1097/sla.0000000000007010","url":null,"abstract":"","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"57 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2026-01-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145986559","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-15DOI: 10.1097/sla.0000000000007011
Riccardo Guastella,Giampaolo Perri,Otto M van Delden,Jan-Fritjof Willemsen,Yuran Dai,Thomas F Stoop,Olivier R Busch,Yuping Shu,Fuye Lin,Poya Ghorbani,Zipeng Lu,Ernesto Sparrelid,Kuirong Jiang,Umberto Cillo,Marc G Besselink,Giovanni Marchegiani
OBJECTIVETo assess the impact of celiac axis stenosis (CAS) on postoperative outcome after pancreatoduodenectomy (PD) and total pancreatectomy (TP), and to describe treatment strategies based on CAS severity and etiology.SUMMARY BACKGROUND DATAAsymptomatic CAS may compromise hepatic and gastric perfusion after PD and TP, potentially increasing morbidity. The role of preoperative CAS detection and treatment remains unknown.METHODSInternational retrospective study at four high-volume centers in four countries (2018-2024). All preoperative CT imaging was re-assessed. CAS >50% stenosis was graded as B/C and considered clinically relevant. Etiology was classified as atherosclerotic, median arcuate ligament [MAL]-related, or mixed. Outcome was associated with CAS severity, etiology, and treatment. Standardized management protocols per center were identified.RESULTSAmong 1,698 patients undergoing PD and TP, CAS was identified in 16% (n=279). CAS grade B/C (6.5%, n=111) was independently associated with severe complications (OR 2.20, P<0.001), bile leak (OR 2.67, P=0.007), liver perfusion failure (OR 2.60, P<0.001), and gastric ischemia (OR 11.29, P<0.001). Outcomes differed by etiology: atherosclerotic CAS was associated with higher bile leak rate (22.7% vs. 5.7%; P=0.018) than MAL-related CAS. Centers with standardized protocols identified and treated CAS more frequently.CONCLUSIONSCAS grade B/C is an underrecognized yet potentially modifiable risk factor for severe complications after PD and TP. Preoperative identification of CAS grade B/C, including etiology, may allow targeted intervention but larger studies are required.
{"title":"Impact of Celiac Axis Stenosis in Patients Undergoing Pancreatoduodenectomy and Total Pancreatectomy: International Multicenter Study.","authors":"Riccardo Guastella,Giampaolo Perri,Otto M van Delden,Jan-Fritjof Willemsen,Yuran Dai,Thomas F Stoop,Olivier R Busch,Yuping Shu,Fuye Lin,Poya Ghorbani,Zipeng Lu,Ernesto Sparrelid,Kuirong Jiang,Umberto Cillo,Marc G Besselink,Giovanni Marchegiani","doi":"10.1097/sla.0000000000007011","DOIUrl":"https://doi.org/10.1097/sla.0000000000007011","url":null,"abstract":"OBJECTIVETo assess the impact of celiac axis stenosis (CAS) on postoperative outcome after pancreatoduodenectomy (PD) and total pancreatectomy (TP), and to describe treatment strategies based on CAS severity and etiology.SUMMARY BACKGROUND DATAAsymptomatic CAS may compromise hepatic and gastric perfusion after PD and TP, potentially increasing morbidity. The role of preoperative CAS detection and treatment remains unknown.METHODSInternational retrospective study at four high-volume centers in four countries (2018-2024). All preoperative CT imaging was re-assessed. CAS >50% stenosis was graded as B/C and considered clinically relevant. Etiology was classified as atherosclerotic, median arcuate ligament [MAL]-related, or mixed. Outcome was associated with CAS severity, etiology, and treatment. Standardized management protocols per center were identified.RESULTSAmong 1,698 patients undergoing PD and TP, CAS was identified in 16% (n=279). CAS grade B/C (6.5%, n=111) was independently associated with severe complications (OR 2.20, P<0.001), bile leak (OR 2.67, P=0.007), liver perfusion failure (OR 2.60, P<0.001), and gastric ischemia (OR 11.29, P<0.001). Outcomes differed by etiology: atherosclerotic CAS was associated with higher bile leak rate (22.7% vs. 5.7%; P=0.018) than MAL-related CAS. Centers with standardized protocols identified and treated CAS more frequently.CONCLUSIONSCAS grade B/C is an underrecognized yet potentially modifiable risk factor for severe complications after PD and TP. Preoperative identification of CAS grade B/C, including etiology, may allow targeted intervention but larger studies are required.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"8 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2026-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145968387","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-06DOI: 10.1097/sla.0000000000007008
Elizabeth Wall-Wieler,Shih-Hao Lee,Yuki Liu,Feibi Zheng
OBJECTIVETo determine the sensitivity of insurance claims codes in identifying robotic-assisted surgery (RAS), assess bias from misclassification, and evaluate the generalizability of findings across data sources.SUMMARY BACKGROUND DATAInsurer-generated databases are widely used to study RAS outcomes, but inconsistent use of claims codes may lead to misclassification and biased estimates.METHODSThis retrospective cohort study compared a test definition (claims only) to a reference definition (claims plus free-text hospital billing data) for identifying RAS from 2018-2023. Two U.S. datasets were used: the Premier Healthcare Database (PHD), a large hospital discharge database, and Merative™, a major claims database for insured employees and dependents. Seven procedures-inguinal hernia repair, cholecystectomy, sleeve gastrectomy, Roux-en-Y gastric bypass, lobectomy, right colectomy, and hysterectomy-were evaluated in inpatient and outpatient settings. Misclassification bias was assessed for operative time, length of stay, conversion to open surgery, and surgical site infection. Generalizability was examined by comparing RAS rates across datasets.RESULTSAmong 2,978,390 procedures in PHD, the sensitivity of claims-only identification was 0.578. Sensitivity exceeded 0.8 for all inpatient procedures across years but was very low for outpatient procedures, falling below 0.5 by 2021. For procedures commonly performed outpatient, effect estimates based on the claims-only definition were frequently biased. RAS rates using the test definition in PHD were generally higher than those observed in the claims-only Merative™ dataset.CONCLUSIONSensitivity of claims data to identify RAS varies by procedure, setting, and time. Low sensitivity causes substantial misclassification bias, impacting analyses of surgical modality and outcomes.
{"title":"Sensitivity of Insurance Claims Codes in Identifying Robotic Assisted Surgery.","authors":"Elizabeth Wall-Wieler,Shih-Hao Lee,Yuki Liu,Feibi Zheng","doi":"10.1097/sla.0000000000007008","DOIUrl":"https://doi.org/10.1097/sla.0000000000007008","url":null,"abstract":"OBJECTIVETo determine the sensitivity of insurance claims codes in identifying robotic-assisted surgery (RAS), assess bias from misclassification, and evaluate the generalizability of findings across data sources.SUMMARY BACKGROUND DATAInsurer-generated databases are widely used to study RAS outcomes, but inconsistent use of claims codes may lead to misclassification and biased estimates.METHODSThis retrospective cohort study compared a test definition (claims only) to a reference definition (claims plus free-text hospital billing data) for identifying RAS from 2018-2023. Two U.S. datasets were used: the Premier Healthcare Database (PHD), a large hospital discharge database, and Merative™, a major claims database for insured employees and dependents. Seven procedures-inguinal hernia repair, cholecystectomy, sleeve gastrectomy, Roux-en-Y gastric bypass, lobectomy, right colectomy, and hysterectomy-were evaluated in inpatient and outpatient settings. Misclassification bias was assessed for operative time, length of stay, conversion to open surgery, and surgical site infection. Generalizability was examined by comparing RAS rates across datasets.RESULTSAmong 2,978,390 procedures in PHD, the sensitivity of claims-only identification was 0.578. Sensitivity exceeded 0.8 for all inpatient procedures across years but was very low for outpatient procedures, falling below 0.5 by 2021. For procedures commonly performed outpatient, effect estimates based on the claims-only definition were frequently biased. RAS rates using the test definition in PHD were generally higher than those observed in the claims-only Merative™ dataset.CONCLUSIONSensitivity of claims data to identify RAS varies by procedure, setting, and time. Low sensitivity causes substantial misclassification bias, impacting analyses of surgical modality and outcomes.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"57 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2026-01-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145903570","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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