Pub Date : 2025-12-22DOI: 10.1097/sla.0000000000007001
Alessandra Borghi,Marco Fiore,Gabriele Tiné,Dirk C Strauss,Sylvie Bonvalot,Chandrajit P Raut,Piotr Rutkowski,Samuel Ford,Carol J Swallow,David E Gyorki,Markus Albertsmeier,Ferdinando Cananzi,Kenneth Cardona,Carolyn Nessim,Valerie Grignol,Elisabetta Pennacchioli,Marko Novak,Shintaro Iwata,Daniela Salvatore,Elena Di Blasi,Michelle Wilkinson,Dimitri Tzanis,Jiping Wang,Jacek Skoczylas,Max Almond,Rebecca A Gladdy,Catherine Mitchell,Andrew Hayes,Sergio Valeri,Rosalba Miceli,Alessandro Gronchi,
OBJECTIVEThis study aimed to prospectively assess the accuracy of preoperative biopsy in primary retroperitoneal sarcoma (RPS) across sarcoma referral centers.SUMMARY BACKGROUND DATAHistological subtype and malignancy grade are key for guiding RPS treatment strategies. However, the accuracy of preoperative biopsy remains uncertain.METHODSData on adult patients with primary localized RPS who underwent preoperative biopsy followed by curative-intent surgery (2017-2020) were collected from the Retroperitoneal Sarcoma Registry. The study aimed to assess concordance between biopsy and surgical specimen histology and grade, using Cohen's kappa statistic. Concordance was also analyzed by center volume (high ≥13 vs. low <13 cases/year).RESULTSOf 894 enrolled patients, histologic concordance was observed in 87.7% of cases (unweighted κ=0.814; 95% CI, 0.773-0.854). Among 172 tumors initially diagnosed as well-differentiated liposarcomas, 44 (25.6%) were reclassified as dedifferentiated liposarcomas. Grade concordance was observed in 232 of 346 cases (76.1%; weighted κ=0.652; 95% CI, 0.589-0.715), with no difference between computed tomography- and ultrasound-guided biopsies. Concordance by tumor grade was 98.9% (grade 1), 62.1% (grade 2), and 40.2% (grade 3). In dedifferentiated liposarcomas, grade concordance was 59.7% (weighted κ=0.385; 95% CI, 0.292-0.479). High-volume centers showed higher concordance for both histology (κ=0.780) and grade (κ=0.680) compared with low-volume centers (κ=0.622 and 0.564, respectively).CONCLUSIONSWhile preoperative biopsy for RPS provides satisfactory histologic accuracy, tumor grade is frequently underestimated. This diagnostic inaccuracy may impact treatment decisions, particularly regarding preoperative therapies. Incorporating additional diagnostic factors may improve the accuracy of preoperative assessment.
{"title":"Accuracy of Histology and Malignancy Grade between Preoperative Biopsy and Surgical Specimens in Primary Retroperitoneal Sarcoma. A Study from the Prospective Retroperitoneal Sarcoma Registry (Resar).","authors":"Alessandra Borghi,Marco Fiore,Gabriele Tiné,Dirk C Strauss,Sylvie Bonvalot,Chandrajit P Raut,Piotr Rutkowski,Samuel Ford,Carol J Swallow,David E Gyorki,Markus Albertsmeier,Ferdinando Cananzi,Kenneth Cardona,Carolyn Nessim,Valerie Grignol,Elisabetta Pennacchioli,Marko Novak,Shintaro Iwata,Daniela Salvatore,Elena Di Blasi,Michelle Wilkinson,Dimitri Tzanis,Jiping Wang,Jacek Skoczylas,Max Almond,Rebecca A Gladdy,Catherine Mitchell,Andrew Hayes,Sergio Valeri,Rosalba Miceli,Alessandro Gronchi, ","doi":"10.1097/sla.0000000000007001","DOIUrl":"https://doi.org/10.1097/sla.0000000000007001","url":null,"abstract":"OBJECTIVEThis study aimed to prospectively assess the accuracy of preoperative biopsy in primary retroperitoneal sarcoma (RPS) across sarcoma referral centers.SUMMARY BACKGROUND DATAHistological subtype and malignancy grade are key for guiding RPS treatment strategies. However, the accuracy of preoperative biopsy remains uncertain.METHODSData on adult patients with primary localized RPS who underwent preoperative biopsy followed by curative-intent surgery (2017-2020) were collected from the Retroperitoneal Sarcoma Registry. The study aimed to assess concordance between biopsy and surgical specimen histology and grade, using Cohen's kappa statistic. Concordance was also analyzed by center volume (high ≥13 vs. low <13 cases/year).RESULTSOf 894 enrolled patients, histologic concordance was observed in 87.7% of cases (unweighted κ=0.814; 95% CI, 0.773-0.854). Among 172 tumors initially diagnosed as well-differentiated liposarcomas, 44 (25.6%) were reclassified as dedifferentiated liposarcomas. Grade concordance was observed in 232 of 346 cases (76.1%; weighted κ=0.652; 95% CI, 0.589-0.715), with no difference between computed tomography- and ultrasound-guided biopsies. Concordance by tumor grade was 98.9% (grade 1), 62.1% (grade 2), and 40.2% (grade 3). In dedifferentiated liposarcomas, grade concordance was 59.7% (weighted κ=0.385; 95% CI, 0.292-0.479). High-volume centers showed higher concordance for both histology (κ=0.780) and grade (κ=0.680) compared with low-volume centers (κ=0.622 and 0.564, respectively).CONCLUSIONSWhile preoperative biopsy for RPS provides satisfactory histologic accuracy, tumor grade is frequently underestimated. This diagnostic inaccuracy may impact treatment decisions, particularly regarding preoperative therapies. Incorporating additional diagnostic factors may improve the accuracy of preoperative assessment.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"36 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2025-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145801328","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 : 2025-12-22DOI: 10.1097/sla.0000000000007005
Sarah Sheskey,Wei San Loh,Kyle H Sheetz
{"title":"Expanding Landscape of Payments from Robotic Surgical Companies to U.S. Providers and Hospitals.","authors":"Sarah Sheskey,Wei San Loh,Kyle H Sheetz","doi":"10.1097/sla.0000000000007005","DOIUrl":"https://doi.org/10.1097/sla.0000000000007005","url":null,"abstract":"","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"3 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2025-12-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145801329","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 : 2025-12-19DOI: 10.1097/sla.0000000000006999
Dong G Hur,Syed M Hameed,Jeff Choi
OBJECTIVECompare trauma activation fees (TAFs) between for-profit and nonprofit trauma centers within granular geographic clusters, accounting for regional market competition and socioeconomic factors.BACKGROUNDTAFs remain unregulated, and evidence suggests higher fees among for-profit centers. Evaluating whether these differences are justified requires examining trauma centers within geographic clusters alongside market and socioeconomic characteristics.METHODSThis cross-sectional study analyzed TAFs at American College of Surgeons Committee-on-Trauma-verified level 1-3 trauma centers. Clusters were identified using hierarchical density-based spatial clustering. We obtained market competition and socioeconomic data of residents within one-hour driving distance. Mixed-effects regression assessed associations between TAFs and ownership status.RESULTSAmong 55 clusters of trauma centers (N=546), 26 included both for-profit and nonprofit centers. Within these, median (IQR) tier 1 TAFs were higher in for-profit centers ($29,000[20,000-38,000] vs. $11,000[7,800-15,000]; P<0.001). Residents near for-profit centers had greater socioeconomic disadvantage (Area-Deprivation-Index: 42.3[27.3] vs. 33.9[28.0], SMD=-0.30) and higher exposure to concentrated markets (Herfindahl-Hirschman Index >2500: 29.4% vs. 14.9%, SMD= 0.56). We found no significant association between TAFs and for-profit status alone (β=870[-2,830-4,580]; P=0.64), but a significant interaction between for-profit status and level 1/2 centers (β=15,300[15,100-15,600]; P<0.001).CONCLUSIONAmong level 1/2 trauma centers, for-profit status was associated with higher TAFs after accounting for clustering, socioeconomic, and market factors. Negotiated payor fees or cash prices remain unclear, yet higher TAFs among for-profit centers warrant further investigation. Until the drivers of TAF differences are clarified, higher fees at for-profit centers and the need for regulation warrant further investigation.
{"title":"Trauma Activation Fees Among For-profit and Nonprofit Trauma Centers: Hierarchical Spatial Clustering Analysis of Regional Market Competition, and Socioeconomic Characteristics of Neighboring Residents.","authors":"Dong G Hur,Syed M Hameed,Jeff Choi","doi":"10.1097/sla.0000000000006999","DOIUrl":"https://doi.org/10.1097/sla.0000000000006999","url":null,"abstract":"OBJECTIVECompare trauma activation fees (TAFs) between for-profit and nonprofit trauma centers within granular geographic clusters, accounting for regional market competition and socioeconomic factors.BACKGROUNDTAFs remain unregulated, and evidence suggests higher fees among for-profit centers. Evaluating whether these differences are justified requires examining trauma centers within geographic clusters alongside market and socioeconomic characteristics.METHODSThis cross-sectional study analyzed TAFs at American College of Surgeons Committee-on-Trauma-verified level 1-3 trauma centers. Clusters were identified using hierarchical density-based spatial clustering. We obtained market competition and socioeconomic data of residents within one-hour driving distance. Mixed-effects regression assessed associations between TAFs and ownership status.RESULTSAmong 55 clusters of trauma centers (N=546), 26 included both for-profit and nonprofit centers. Within these, median (IQR) tier 1 TAFs were higher in for-profit centers ($29,000[20,000-38,000] vs. $11,000[7,800-15,000]; P<0.001). Residents near for-profit centers had greater socioeconomic disadvantage (Area-Deprivation-Index: 42.3[27.3] vs. 33.9[28.0], SMD=-0.30) and higher exposure to concentrated markets (Herfindahl-Hirschman Index >2500: 29.4% vs. 14.9%, SMD= 0.56). We found no significant association between TAFs and for-profit status alone (β=870[-2,830-4,580]; P=0.64), but a significant interaction between for-profit status and level 1/2 centers (β=15,300[15,100-15,600]; P<0.001).CONCLUSIONAmong level 1/2 trauma centers, for-profit status was associated with higher TAFs after accounting for clustering, socioeconomic, and market factors. Negotiated payor fees or cash prices remain unclear, yet higher TAFs among for-profit centers warrant further investigation. Until the drivers of TAF differences are clarified, higher fees at for-profit centers and the need for regulation warrant further investigation.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"20 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2025-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145777495","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 : 2025-12-19DOI: 10.1097/sla.0000000000006997
James Luketich,Inderpal Sarkaria,Ryan Levy,Evan Alicuben,William E Gooding,Peter Davis,Omar Awais,Neil Christie,Renee Levesque,Julie Ward,John Ryan,Matthew Schuchert,Arjun Pennathur,
OBJECTIVETo assess the value of adding of a pyloroplasty procedure during the performance of minimally invasive esophagectomy (MIE) or robotically assisted MIE (RAMIE), we conducted a prospective, phase III randomized controlled trial (RCT)(NCT03740542).BACKGROUNDMany surgeons include pyloroplasty when performing esophagectomy, but few studies have provided level 1 evidence to support or refute this step especially in the era of MIE and RAMIE.METHODSAn adaptive randomization trial design was utilized to maximize patients treated on more effective therapy and conversely minimize accrual to a less effective procedure. The trial was designed to proceed until one arm was established as superior or until a total of 140 patients had been treated and deemed evaluable for response. The primary endpoints of the study were pneumonia and/or anastomotic leak requiring surgery within 30 days of surgery.RESULTSOver a 4-year period, 143 patients were randomized, and 134 patients were evaluable. The greater likelihood of success for pyloroplasty throughout the trial resulted in more patients randomized towards pyloroplasty (n= 90) vs. no pyloroplasty (n=44). Pneumonia or an anastomotic leak occurred in 16 of 90 (18%) patients in the pyloroplasty arm vs. 12 of 44 (27%) in the no-pyloroplasty arm. The stopping criteria were met when the posterior probability of pyloroplasty being superior reached 90%.CONCLUSIONSThe design of this trial led to early stopping because the short-term results indicated that outcomes in the pyloroplasty arm were superior to the no-pyloroplasty arm. This RCT provides evidence for short-term benefits of adding pyloroplasty to MIE or RAMIE. The long-term outcomes and quality of life measures continue to be monitored.
{"title":"A Phase III Randomized Controlled Trial of Pyloroplasty versus No Pyloroplasty in Patients Undergoing Minimally Invasive Esophagectomy or Robot-Assisted Minimally Invasive Esophagectomy.","authors":"James Luketich,Inderpal Sarkaria,Ryan Levy,Evan Alicuben,William E Gooding,Peter Davis,Omar Awais,Neil Christie,Renee Levesque,Julie Ward,John Ryan,Matthew Schuchert,Arjun Pennathur, ","doi":"10.1097/sla.0000000000006997","DOIUrl":"https://doi.org/10.1097/sla.0000000000006997","url":null,"abstract":"OBJECTIVETo assess the value of adding of a pyloroplasty procedure during the performance of minimally invasive esophagectomy (MIE) or robotically assisted MIE (RAMIE), we conducted a prospective, phase III randomized controlled trial (RCT)(NCT03740542).BACKGROUNDMany surgeons include pyloroplasty when performing esophagectomy, but few studies have provided level 1 evidence to support or refute this step especially in the era of MIE and RAMIE.METHODSAn adaptive randomization trial design was utilized to maximize patients treated on more effective therapy and conversely minimize accrual to a less effective procedure. The trial was designed to proceed until one arm was established as superior or until a total of 140 patients had been treated and deemed evaluable for response. The primary endpoints of the study were pneumonia and/or anastomotic leak requiring surgery within 30 days of surgery.RESULTSOver a 4-year period, 143 patients were randomized, and 134 patients were evaluable. The greater likelihood of success for pyloroplasty throughout the trial resulted in more patients randomized towards pyloroplasty (n= 90) vs. no pyloroplasty (n=44). Pneumonia or an anastomotic leak occurred in 16 of 90 (18%) patients in the pyloroplasty arm vs. 12 of 44 (27%) in the no-pyloroplasty arm. The stopping criteria were met when the posterior probability of pyloroplasty being superior reached 90%.CONCLUSIONSThe design of this trial led to early stopping because the short-term results indicated that outcomes in the pyloroplasty arm were superior to the no-pyloroplasty arm. This RCT provides evidence for short-term benefits of adding pyloroplasty to MIE or RAMIE. The long-term outcomes and quality of life measures continue to be monitored.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"6 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2025-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145777497","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 : 2025-12-18DOI: 10.1097/sla.0000000000007000
Josefina Principe,Cristian A Angeramo,José Barros Sosa,Juan J Baz Gallego,Fernando A M Herbella,Marco G Patti,Francisco Schlottmann
OBJECTIVEThe aim of this meta-analysis was to evaluate long-term outcomes and patient-reported satisfaction after LNF.SUMMARY BACKGROUND DATALaparoscopic Nissen fundoplication (LNF) has demonstrated short- and mid-term symptom relief in patients with gastroesophageal reflux disease (GERD). However, long-term outcomes have not been clearly defined.METHODSA systematic PubMed search identified studies of LNF for GERD with ≥10-year follow-up. The main outcome was effectiveness of the operation, which was determined by symptomatic improvement, esophagitis improvement, and proton-pump inhibitors (PPIs) use. Secondary endpoints included adverse events, patient satisfaction and willingness to undergo LNF again. A meta-analysis of proportions was performed to calculate weighted pooled estimates with 95% confidence intervals, and paired t-tests compared pre- and postoperative symptoms.RESULTSA total of 12 studies comprising 1,334 patients were analyzed. The mean follow-up across studies was 13.1 (10-22) years. The presence of heartburn decreased from 94.2% to 33.7% (P<0.001), regurgitation from 68.7% to 13.4% (P=0.02), and esophagitis from 61.7% to 7.4% (P=0.001). The weighted pooled proportion of symptom recurrence was 17% (95% CI, 5%-47%). Postoperative PPIs use was reported in 24% (95% CI, 14%-38%) of patients. Gas-bloating and dysphagia occurred in 53% (95% CI, 20%-83%) and 26% (95% CI, 18%-37%) of patients. Overall patient satisfaction was 87% (95% CI, 81%-92%), and 87% of patients (95% CI, 82%-90%) reported willingness to undergo LNF again. The proportion of patients requiring reoperation was 6% (95% CI, 3%-9%).CONCLUSIONSLNF provides durable long-term improvement of GERD symptoms. Although postoperative gas-bloating and dysphagia are frequent, long-term patients' satisfaction is high.
{"title":"Long-Term (>10 Years) Outcomes of Laparoscopic Nissen Fundoplication: A Systematic Review and Meta-Analysis.","authors":"Josefina Principe,Cristian A Angeramo,José Barros Sosa,Juan J Baz Gallego,Fernando A M Herbella,Marco G Patti,Francisco Schlottmann","doi":"10.1097/sla.0000000000007000","DOIUrl":"https://doi.org/10.1097/sla.0000000000007000","url":null,"abstract":"OBJECTIVEThe aim of this meta-analysis was to evaluate long-term outcomes and patient-reported satisfaction after LNF.SUMMARY BACKGROUND DATALaparoscopic Nissen fundoplication (LNF) has demonstrated short- and mid-term symptom relief in patients with gastroesophageal reflux disease (GERD). However, long-term outcomes have not been clearly defined.METHODSA systematic PubMed search identified studies of LNF for GERD with ≥10-year follow-up. The main outcome was effectiveness of the operation, which was determined by symptomatic improvement, esophagitis improvement, and proton-pump inhibitors (PPIs) use. Secondary endpoints included adverse events, patient satisfaction and willingness to undergo LNF again. A meta-analysis of proportions was performed to calculate weighted pooled estimates with 95% confidence intervals, and paired t-tests compared pre- and postoperative symptoms.RESULTSA total of 12 studies comprising 1,334 patients were analyzed. The mean follow-up across studies was 13.1 (10-22) years. The presence of heartburn decreased from 94.2% to 33.7% (P<0.001), regurgitation from 68.7% to 13.4% (P=0.02), and esophagitis from 61.7% to 7.4% (P=0.001). The weighted pooled proportion of symptom recurrence was 17% (95% CI, 5%-47%). Postoperative PPIs use was reported in 24% (95% CI, 14%-38%) of patients. Gas-bloating and dysphagia occurred in 53% (95% CI, 20%-83%) and 26% (95% CI, 18%-37%) of patients. Overall patient satisfaction was 87% (95% CI, 81%-92%), and 87% of patients (95% CI, 82%-90%) reported willingness to undergo LNF again. The proportion of patients requiring reoperation was 6% (95% CI, 3%-9%).CONCLUSIONSLNF provides durable long-term improvement of GERD symptoms. Although postoperative gas-bloating and dysphagia are frequent, long-term patients' satisfaction is high.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"21 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2025-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145771436","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 : 2025-12-17DOI: 10.1097/sla.0000000000007002
Nicolò Pecorelli,Francesca Fermi,Fariba Abbassi,Elisa Bannone,Giovanni Capretti,Elena Desiato,Gabriele Di Lucca,Greta Donisi,Alessandro Fogliati,Isabella Frigerio,Giovanni Guarneri,Federico Gronchi,Katharina L Lucas,Salvatore Paiella,Michaela Ramser,Marta Sandini,Alessia Vallorani,Giovanni Butturini,Luca Gianotti,Roberto Salvia,Alessandro Zerbi,Julio F Fiore,Pierre-Alain Clavien,Massimo Falconi
OBJECTIVETo assess the reliability and construct validity of the CCI®️ following pancreatic surgery.SUMMARY BACKGROUND DATAThe Comprehensive Complication Index (CCI®️) is the only validated metric that quantifies cumulative morbidity, with a continuous score ranging from 0 (no complications) to 100 (death).METHODSTo address construct validity, we assessed patients undergoing elective pancreatic surgery for any disease at five Italian centers enrolled in a randomized controlled trial (NCT04438447) and a prospective cohort study (NCT04431076). The severity of 90-day complications was assessed using the CCI®️. We tested 10 a priori construct validity hypotheses through linear regression. Regression coefficients represented the between-group mean difference in CCI®️, with an effect size ≥0.2 considered potentially meaningful. Validity was deemed adequate if >75% of the hypotheses were supported. To address reliability, three independent raters among six centers assessed the CCI®️ from 100 anonymous case vignettes to evaluate inter-rater and inter-center reliability through intraclass correlation coefficient (ICC) and standard error of measurement (SEM).RESULTS797 patients were included (66±11 y, 50% female, 60% malignancy). The construct validity was supported by data, with 9/10 a priori hypotheses confirmed (90%). The CCI®️ showed excellent inter-rater (ICC=0.96, 95%CI: 0.95-0.97), high inter-center reliability (ICC >0.75 in each center), with a SEM ranging from 2.73 to 6.38.CONCLUSIONSThis study supports CCI®️as a valid and reliable measure of morbidity after pancreatic surgery, supporting its use in both clinical practice and comparative effectiveness research.
{"title":"Construct Validity and Reliability of the Comprehensive Complication Index as a Morbidity Outcome Measure in Pancreatic Surgery.","authors":"Nicolò Pecorelli,Francesca Fermi,Fariba Abbassi,Elisa Bannone,Giovanni Capretti,Elena Desiato,Gabriele Di Lucca,Greta Donisi,Alessandro Fogliati,Isabella Frigerio,Giovanni Guarneri,Federico Gronchi,Katharina L Lucas,Salvatore Paiella,Michaela Ramser,Marta Sandini,Alessia Vallorani,Giovanni Butturini,Luca Gianotti,Roberto Salvia,Alessandro Zerbi,Julio F Fiore,Pierre-Alain Clavien,Massimo Falconi","doi":"10.1097/sla.0000000000007002","DOIUrl":"https://doi.org/10.1097/sla.0000000000007002","url":null,"abstract":"OBJECTIVETo assess the reliability and construct validity of the CCI®️ following pancreatic surgery.SUMMARY BACKGROUND DATAThe Comprehensive Complication Index (CCI®️) is the only validated metric that quantifies cumulative morbidity, with a continuous score ranging from 0 (no complications) to 100 (death).METHODSTo address construct validity, we assessed patients undergoing elective pancreatic surgery for any disease at five Italian centers enrolled in a randomized controlled trial (NCT04438447) and a prospective cohort study (NCT04431076). The severity of 90-day complications was assessed using the CCI®️. We tested 10 a priori construct validity hypotheses through linear regression. Regression coefficients represented the between-group mean difference in CCI®️, with an effect size ≥0.2 considered potentially meaningful. Validity was deemed adequate if >75% of the hypotheses were supported. To address reliability, three independent raters among six centers assessed the CCI®️ from 100 anonymous case vignettes to evaluate inter-rater and inter-center reliability through intraclass correlation coefficient (ICC) and standard error of measurement (SEM).RESULTS797 patients were included (66±11 y, 50% female, 60% malignancy). The construct validity was supported by data, with 9/10 a priori hypotheses confirmed (90%). The CCI®️ showed excellent inter-rater (ICC=0.96, 95%CI: 0.95-0.97), high inter-center reliability (ICC >0.75 in each center), with a SEM ranging from 2.73 to 6.38.CONCLUSIONSThis study supports CCI®️as a valid and reliable measure of morbidity after pancreatic surgery, supporting its use in both clinical practice and comparative effectiveness research.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"50 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2025-12-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145765443","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 : 2025-12-12DOI: 10.1097/sla.0000000000006995
Max M Judish,Charles M Vollmer,
OBJECTIVETo identify optimal approaches to fistula mitigation for pancreatoduodenectomy.BACKGROUNDPostoperative Pancreatic Fistula (POPF) is the most consequential complication following pancreatoduodenectomy (PD). To date, the various POPF prevention methods have been investigated predominantly in isolation; however, the complexity of PD demands studying the interplay between approaches.METHODS7128 PDs with complete POPF, Fistula Risk Score (FRS), and mitigation data were performed from 2000-2024 between 18 international institutions. Techniques analyzed were: drains, stents, octreotide, pancreatogastrostomy, and sealants. POPF was tabulated for strategy combinations, accounting for FRS. The additive effect of early drain removal (EDR; POD≤4) was assessed.RESULTSThe fistula rate was 15.1%. Mitigation application rates were drains=94.0%; stents=37.4%; octreotide=21.2%; pancreatogastrostomy=3.5%; and sealants=3.3%. Analyzed individually, drains were not associated with POPF, while stents, octreotide, pancreatogastrostomy, and sealants were associated with increased POPF. Risk adjustment revealed nuance among the 27 observed mitigation combinations. For Negligible and Low FRS patients, no approach improved upon omission. Drain-alone was best for Moderate FRS patients (POPF: 13.1% vs. 19.8%, P<0.001). Best outcomes for High FRS patients were achieved by employing Drain+Stent (23.7% vs. 38.5%, P<0.001). These results inform a "playbook" of optimal management. Increased adherence to these tenets was associated with improved surgeon practice-level fistula rates (P=0.034). Universal adoption of optimal fistula mitigation projects to eliminate from one-third of fistulas, up to one-half when incorporating EDR.CONCLUSIONThis robust experience indicates that many frequently employed fistula mitigation tactics are actually ineffective. Conversely, the optimal approaches identified herein are underutilized-in just 32% of patients. Simplified, tailored application can drive down stubborn fistula rates, enhance care, and move toward personalized medicine for fistula prevention.
目的探讨胰十二指肠切除术中减少瘘管的最佳方法。背景术后胰瘘（POPF）是胰十二指肠切除术（PD）后最严重的并发症。迄今为止，主要在隔离情况下研究了各种预防POPF的方法；然而，PD的复杂性要求研究各种方法之间的相互作用。方法从2000年至2024年，在18个国际机构中进行了7128例具有完整的POPF、瘘风险评分（FRS）和缓解数据的pd。分析的技术包括：引流管、支架、奥曲肽、胰胃造口术和密封剂。将策略组合的POPF制成表格，计入FRS，评估早期引流去除的加性效应（EDR, POD≤4）。结果瘘管发生率为15.1%。缓释施用率为排水沟=94.0%；支架= 37.4%;octreotide = 21.2%;pancreatogastrostomy = 3.5%;和密封剂= 3.3%。单独分析，引流管与POPF无关，而支架、奥曲肽、胰胃造口术和密封剂与POPF增加相关。风险调整揭示了27种观察到的缓解组合之间的细微差别。对于可忽略和低FRS患者，没有任何方法在遗漏后得到改善。单独引流对中度FRS患者最好（POPF: 13.1% vs. 19.8%， P<0.001）。采用引流+支架治疗高FRS患者效果最佳（23.7% vs 38.5%， P<0.001）。这些结果为最佳管理提供了“剧本”。加强对这些原则的遵守与外科医生实践水平瘘发生率的提高相关（P=0.034）。普遍采用最佳的瘘管缓解项目，将瘘管从三分之一减少到二分之一，如果纳入电子药物治疗。结论：这一强有力的经验表明，许多常用的瘘缓解策略实际上是无效的。相反，本文确定的最佳方法未得到充分利用，只有32%的患者未得到充分利用。简化，量身定制的应用可以降低顽固瘘管率，加强护理，并朝着个性化医疗瘘管预防。
{"title":"Elucidating the Optimal Use of Mitigation Strategies for Improving Pancreatic Fistula Rates after Pancreatoduodenectomy.","authors":"Max M Judish,Charles M Vollmer, ","doi":"10.1097/sla.0000000000006995","DOIUrl":"https://doi.org/10.1097/sla.0000000000006995","url":null,"abstract":"OBJECTIVETo identify optimal approaches to fistula mitigation for pancreatoduodenectomy.BACKGROUNDPostoperative Pancreatic Fistula (POPF) is the most consequential complication following pancreatoduodenectomy (PD). To date, the various POPF prevention methods have been investigated predominantly in isolation; however, the complexity of PD demands studying the interplay between approaches.METHODS7128 PDs with complete POPF, Fistula Risk Score (FRS), and mitigation data were performed from 2000-2024 between 18 international institutions. Techniques analyzed were: drains, stents, octreotide, pancreatogastrostomy, and sealants. POPF was tabulated for strategy combinations, accounting for FRS. The additive effect of early drain removal (EDR; POD≤4) was assessed.RESULTSThe fistula rate was 15.1%. Mitigation application rates were drains=94.0%; stents=37.4%; octreotide=21.2%; pancreatogastrostomy=3.5%; and sealants=3.3%. Analyzed individually, drains were not associated with POPF, while stents, octreotide, pancreatogastrostomy, and sealants were associated with increased POPF. Risk adjustment revealed nuance among the 27 observed mitigation combinations. For Negligible and Low FRS patients, no approach improved upon omission. Drain-alone was best for Moderate FRS patients (POPF: 13.1% vs. 19.8%, P<0.001). Best outcomes for High FRS patients were achieved by employing Drain+Stent (23.7% vs. 38.5%, P<0.001). These results inform a \"playbook\" of optimal management. Increased adherence to these tenets was associated with improved surgeon practice-level fistula rates (P=0.034). Universal adoption of optimal fistula mitigation projects to eliminate from one-third of fistulas, up to one-half when incorporating EDR.CONCLUSIONThis robust experience indicates that many frequently employed fistula mitigation tactics are actually ineffective. Conversely, the optimal approaches identified herein are underutilized-in just 32% of patients. Simplified, tailored application can drive down stubborn fistula rates, enhance care, and move toward personalized medicine for fistula prevention.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"49 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2025-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145728566","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 : 2025-12-11DOI: 10.1097/sla.0000000000006993
Yasmin Arda,Vahe S Panossian,Ikemsinachi C Nzenwa,John O Hwabejire,Michael P DeWane,Charudutt N Paranjape,Joshua S Ng-Kamstra,Jonathan Parks,Katherine Albutt,George C Velmahos,Haytham M A Kaafarani
OBJECTIVEThis study aimed to evaluate the impact of hospital blunt intestinal injury (BInI) trauma volume on time to surgery in patients with BInI.SUMMARY OF BACKGROUND DATAThe diagnosis of BInI is challenging, even for trauma experts, leading to frequent delays in necessary surgical intervention.METHODSThe 2017-2020 ACS-TQIP database was used to identify patients ≥18 years with full-thickness ileal, jejunal, or colonic perforation secondary to blunt trauma. Hospitals were stratified by the annual volume of BInI. Multivariable logistic regression adjusting for demographics, comorbidities, and injury characteristics/severity was used to study the impact of hospital trauma volume on delayed surgery (>24 hours) and outcomes (e.g. mortality, sepsis). Sensitivity analyses were performed classifying hospitals by their volume of (1) blunt trauma and (2) all trauma admissions.RESULTSOut of a total of 4,005,762 trauma patients, 3,954 were included: 1,397 (35.3%) in low BInI volume, 1,373 (34.7%) in medium BInI volume, and 1,184 (30%) in high BInI volume hospitals. The mean time to surgery was 18±46 hours in low-volume compared to 15±45 hours in high-volume hospitals (P<0.001). On multivariable analysis, high BInI volume was independently associated with early surgery (aOR for delayed surgery 0.68, 95% CI 0.53-0.88) and a 42% lower risk of post-injury sepsis (aOR 0.58, 95% CI 0.37-0.91) compared to low BInI volume. High blunt trauma and all trauma hospital volumes were similarly associated with early surgery (aOR 0.65, 95% CI 0.51-0.84; aOR 0.66, 95% CI 0.51-0.85, respectively).CONCLUSIONSHigh trauma hospital volume is independently associated with prompt surgical intervention and improved outcomes in patients with BInI. These findings highlight the importance of clinical trauma experience and available resources for trauma care in early diagnosis and management of the rare and tricky intestinal injuries.
目的探讨医院钝性肠损伤（BInI）外伤量对BInI患者手术时间的影响。背景数据总结：即使对创伤专家来说，BInI的诊断也是具有挑战性的，导致必要的手术干预经常延迟。方法2017-2020 ACS-TQIP数据库用于识别≥18岁的钝性创伤致全厚度回肠、空肠或结肠穿孔患者。按年度BInI量对医院进行分层。采用调整人口统计学、合并症和损伤特征/严重程度的多变量logistic回归来研究医院创伤量对延迟手术（bbb24小时）和结局（如死亡率、败血症）的影响。根据(1)钝性创伤和(2)所有创伤入院量对医院进行敏感性分析。结果共纳入4005762例创伤患者，其中低BInI医院1397例（35.3%），中等BInI医院1373例（34.7%），高BInI医院1184例（30%）。小容量医院的平均手术时间为18±46小时，而大容量医院为15±45小时（P<0.001）。在多变量分析中，与低BInI容量相比，高BInI容量与早期手术（延迟手术的aOR为0.68,95% CI 0.53-0.88）和损伤后脓毒症风险降低42% （aOR为0.58,95% CI 0.37-0.91）独立相关。高钝性创伤和所有创伤医院容量同样与早期手术相关（分别为aOR 0.65, 95% CI 0.51-0.84; aOR 0.66, 95% CI 0.51-0.85）。结论高创伤住院容量与颅脑损伤患者及时手术干预和改善预后独立相关。这些发现强调了临床创伤经验和现有资源对早期诊断和治疗罕见和棘手的肠道损伤的重要性。
{"title":"Rare and Tricky: The Relationship Between Hospital Trauma Volume and Delay in Surgical Intervention in Blunt Intestinal Injury.","authors":"Yasmin Arda,Vahe S Panossian,Ikemsinachi C Nzenwa,John O Hwabejire,Michael P DeWane,Charudutt N Paranjape,Joshua S Ng-Kamstra,Jonathan Parks,Katherine Albutt,George C Velmahos,Haytham M A Kaafarani","doi":"10.1097/sla.0000000000006993","DOIUrl":"https://doi.org/10.1097/sla.0000000000006993","url":null,"abstract":"OBJECTIVEThis study aimed to evaluate the impact of hospital blunt intestinal injury (BInI) trauma volume on time to surgery in patients with BInI.SUMMARY OF BACKGROUND DATAThe diagnosis of BInI is challenging, even for trauma experts, leading to frequent delays in necessary surgical intervention.METHODSThe 2017-2020 ACS-TQIP database was used to identify patients ≥18 years with full-thickness ileal, jejunal, or colonic perforation secondary to blunt trauma. Hospitals were stratified by the annual volume of BInI. Multivariable logistic regression adjusting for demographics, comorbidities, and injury characteristics/severity was used to study the impact of hospital trauma volume on delayed surgery (>24 hours) and outcomes (e.g. mortality, sepsis). Sensitivity analyses were performed classifying hospitals by their volume of (1) blunt trauma and (2) all trauma admissions.RESULTSOut of a total of 4,005,762 trauma patients, 3,954 were included: 1,397 (35.3%) in low BInI volume, 1,373 (34.7%) in medium BInI volume, and 1,184 (30%) in high BInI volume hospitals. The mean time to surgery was 18±46 hours in low-volume compared to 15±45 hours in high-volume hospitals (P<0.001). On multivariable analysis, high BInI volume was independently associated with early surgery (aOR for delayed surgery 0.68, 95% CI 0.53-0.88) and a 42% lower risk of post-injury sepsis (aOR 0.58, 95% CI 0.37-0.91) compared to low BInI volume. High blunt trauma and all trauma hospital volumes were similarly associated with early surgery (aOR 0.65, 95% CI 0.51-0.84; aOR 0.66, 95% CI 0.51-0.85, respectively).CONCLUSIONSHigh trauma hospital volume is independently associated with prompt surgical intervention and improved outcomes in patients with BInI. These findings highlight the importance of clinical trauma experience and available resources for trauma care in early diagnosis and management of the rare and tricky intestinal injuries.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"8 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145718023","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 : 2025-12-11DOI: 10.1097/sla.0000000000006992
Shahrzad Arya,Marco Ventin,Liti Zhang,Carlos Fernandez-Del Castillo,Alexandra Gangi,Nicholas Nissen,Kambiz Kosari,Giulia Cattaneo,Motaz Qadan,Keith D Lillemoe,Andrew L Warshaw,Cristina R Ferrone
OBJECTIVETo compare the short- and long-term outcomes of the Warshaw (splenic vessel resection) and Kimura (splenic vessel preservation) techniques in spleen-preserving distal pancreatectomy (SPDP).SUMMARY BACKGROUND DATASPDP is an alternative to splenectomy that preserves immune function. Both Warshaw and Kimura are used, but comparative data on their long-term safety and indications are limited.METHODSRetrospective bi-institutional analysis of 297 patients undergoing SPDP at Massachusetts General Hospital and Cedars-Sinai Medical Center (2002-2020). Clinicopathologic, operative, and radiologic outcomes were compared.RESULTSOf 297 patients, 245 (82.5%) underwent Warshaw and 52 (17.5%) Kimura. Warshaw was more commonly performed for larger tumors (2.5 cm vs. 1.5 cm, P<0.001), proximal lesions (specimen 8.2 cm vs. 5.7 cm, P<0.001), and malignant or complex disease, Kimura was more commonly performed minimally invasively (MIS) (73.1% vs. 44.1%, P<0.001) and was associated with shorter operative time. Higher ASA class, larger tumor size, pancreatic ductal adenocarcinoma, and the Warshaw technique independently predicted longer operative time in MIS cases, suggesting a preferential adoption of the Warshaw technique for technically more challenging tumor dissections. Short-term morbidity, readmission, and mortality rates were comparable. With a median follow-up of 85.8 monthssplenic hypoperfusion (30.4% vs. 12.2%, P=0.010), and perigastric varices (19.6% vs. 7.3%, P=0.056) were more frequent after Warshaw, although most were clinically silent, and the need for secondary splenectomy was rare (1.2%).CONCLUSIONSBoth techniques are safe and effective for SPDP. Warshaw is preferred for proximal, malignant, or complex lesions, while Kimura may minimize long-term splenic sequelae in small, distal, benign tumors. An anatomy- and disease-driven approach remains essential to optimize outcomes.
目的比较Warshaw（脾血管切除）技术和Kimura（脾血管保留）技术在保脾远端胰腺切除术（SPDP）中的近期和远期疗效。背景：aspdp是脾切除术的替代选择，可保留免疫功能。Warshaw和Kimura都被使用，但关于其长期安全性和适应症的比较数据有限。方法回顾性分析2002-2020年在马萨诸塞州总医院和雪松-西奈医学中心接受SPDP治疗的297例患者。比较临床病理、手术和放射学结果。结果297例患者中，Warshaw手术245例（82.5%），Kimura手术52例（17.5%）。Warshaw更常用于较大的肿瘤（2.5 cm对1.5 cm， P<0.001）、近端病变（标本8.2 cm对5.7 cm， P<0.001）和恶性或复杂疾病，Kimura更常用于微创（MIS）（73.1%对44.1%，P<0.001），并与较短的手术时间相关。较高的ASA等级、较大的肿瘤大小、胰腺导管腺癌和Warshaw技术独立预测MIS病例更长的手术时间，提示在技术上更具挑战性的肿瘤解剖中优先采用Warshaw技术。短期发病率、再入院率和死亡率具有可比性。中位随访时间为85.8个月，Warshaw术后脾灌注不足（30.4% vs. 12.2%， P=0.010）和胃周静脉曲张（19.6% vs. 7.3%， P=0.056）更为常见，尽管大多数患者临床无症状，且需要二次脾切除术的病例很少（1.2%）。结论两种方法治疗SPDP安全有效。Warshaw手术适用于近端、恶性或复杂病变，而Kimura手术可减少远端、良性肿瘤的长期脾后遗症。解剖学和疾病驱动的方法仍然是优化结果的关键。
{"title":"Long-term Outcomes of Spleen-preserving Distal Pancreatectomy With or Without Preservation of Splenic Vessels: A Bi-institutional Experience.","authors":"Shahrzad Arya,Marco Ventin,Liti Zhang,Carlos Fernandez-Del Castillo,Alexandra Gangi,Nicholas Nissen,Kambiz Kosari,Giulia Cattaneo,Motaz Qadan,Keith D Lillemoe,Andrew L Warshaw,Cristina R Ferrone","doi":"10.1097/sla.0000000000006992","DOIUrl":"https://doi.org/10.1097/sla.0000000000006992","url":null,"abstract":"OBJECTIVETo compare the short- and long-term outcomes of the Warshaw (splenic vessel resection) and Kimura (splenic vessel preservation) techniques in spleen-preserving distal pancreatectomy (SPDP).SUMMARY BACKGROUND DATASPDP is an alternative to splenectomy that preserves immune function. Both Warshaw and Kimura are used, but comparative data on their long-term safety and indications are limited.METHODSRetrospective bi-institutional analysis of 297 patients undergoing SPDP at Massachusetts General Hospital and Cedars-Sinai Medical Center (2002-2020). Clinicopathologic, operative, and radiologic outcomes were compared.RESULTSOf 297 patients, 245 (82.5%) underwent Warshaw and 52 (17.5%) Kimura. Warshaw was more commonly performed for larger tumors (2.5 cm vs. 1.5 cm, P<0.001), proximal lesions (specimen 8.2 cm vs. 5.7 cm, P<0.001), and malignant or complex disease, Kimura was more commonly performed minimally invasively (MIS) (73.1% vs. 44.1%, P<0.001) and was associated with shorter operative time. Higher ASA class, larger tumor size, pancreatic ductal adenocarcinoma, and the Warshaw technique independently predicted longer operative time in MIS cases, suggesting a preferential adoption of the Warshaw technique for technically more challenging tumor dissections. Short-term morbidity, readmission, and mortality rates were comparable. With a median follow-up of 85.8 monthssplenic hypoperfusion (30.4% vs. 12.2%, P=0.010), and perigastric varices (19.6% vs. 7.3%, P=0.056) were more frequent after Warshaw, although most were clinically silent, and the need for secondary splenectomy was rare (1.2%).CONCLUSIONSBoth techniques are safe and effective for SPDP. Warshaw is preferred for proximal, malignant, or complex lesions, while Kimura may minimize long-term splenic sequelae in small, distal, benign tumors. An anatomy- and disease-driven approach remains essential to optimize outcomes.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"4 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145718022","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 evaluate real-world clinical outcomes of robotic pancreaticoduodenectomy (PD) versus open and laparoscopic PD in a nationwide cohort.SUMMARY BACKGROUND DATAWhile robotic PD has gained popularity as a minimally invasive approach to pancreatic surgery, its clinical effectiveness remains uncertain owing to the limited generalizability of existing evidence.METHODSData from the Japanese National Clinical Database, which captures over 95% of surgical procedures conducted nationwide, were analyzed. Patients who underwent PD between January 2019 and December 2023 were included. Propensity score matching was used to compare robotic PD with open and laparoscopic PD.RESULTSAmong 46,166 eligible PD cases, 1,371 were robotic. To ensure consistent surgical proficiency, the analysis included cases performed at institutions conducting ≥20 PDs annually (n=23,613). Following 1:1 matching, 1,248 robotic-open and 1,066 robotic-laparoscopic pairs were identified. Robotic PD was associated with a lower severe complication incidence than that with open (22.2% vs. 25.9%; odds ratio, 0.82; 95% confidence interval, 0.68-0.98; P=0.031) and laparoscopic PD (23.0% vs. 27.6%; odds ratio, 0.78; 95% confidence interval, 0.64-0.95; P=0.015). Robotic PD was also associated with a lower incidence of pancreatic fistula and shorter hospital stay, despite extended operative time. An increased incidence of deep venous thrombosis was observed in the robotic PD group.CONCLUSIONSIn this nationwide, Japanese credentialed setting, robotic PD was associated with improved short‑term outcomes compared with those of open and laparoscopic PD. As PD outcomes are influenced by surgeon/institutional experience and case complexity (tumor factors), these aspects should be carefully considered when selecting robotic PD.
目的在全国队列中评估机器人胰十二指肠切除术（PD）与开放和腹腔镜PD的实际临床结果。虽然机器人PD作为一种微创胰腺手术方法越来越受欢迎，但由于现有证据的可推广性有限，其临床有效性仍不确定。方法分析来自日本国家临床数据库的数据，该数据库捕获了全国95%以上的外科手术。纳入了2019年1月至2023年12月期间接受PD治疗的患者。倾向评分匹配用于比较机器人PD与开放和腹腔镜PD。结果在46,166例符合条件的PD病例中，1,371例是机器人。为了确保一致的手术熟练程度，分析纳入了每年进行≥20例pd的机构的病例（n=23,613）。按照1:1的匹配，确定了1248对机器人开放和1066对机器人腹腔镜。机器人PD的严重并发症发生率低于开放式PD （22.2% vs. 25.9%；优势比0.82；95%可信区间，0.68-0.98；P=0.031）和腹腔镜PD （23.0% vs. 27.6%；优势比0.78；95%可信区间，0.64-0.95；P=0.015）。机器人PD也与较低的胰瘘发生率和较短的住院时间相关，尽管手术时间延长。在机器人PD组中观察到深静脉血栓的发生率增加。结论：在日本全国范围内，与开放和腹腔镜PD相比，机器人PD具有改善的短期预后。由于PD的结果受外科医生/机构经验和病例复杂性（肿瘤因素）的影响，因此在选择机器人PD时应仔细考虑这些方面。
{"title":"Robotic Versus Open and Laparoscopic Pancreaticoduodenectomy: A Nationwide Matched Study in Japan.","authors":"Naoki Ikenaga,Hiraku Kumamaru,Masafumi Inomata,Naoko Kinukawa,Toshimitsu Iwasaki,Koki Otsuka,Hideki Ueno,Yuko Kitagawa,Ken Shirabe,Masafumi Nakamura","doi":"10.1097/sla.0000000000006996","DOIUrl":"https://doi.org/10.1097/sla.0000000000006996","url":null,"abstract":"OBJECTIVETo evaluate real-world clinical outcomes of robotic pancreaticoduodenectomy (PD) versus open and laparoscopic PD in a nationwide cohort.SUMMARY BACKGROUND DATAWhile robotic PD has gained popularity as a minimally invasive approach to pancreatic surgery, its clinical effectiveness remains uncertain owing to the limited generalizability of existing evidence.METHODSData from the Japanese National Clinical Database, which captures over 95% of surgical procedures conducted nationwide, were analyzed. Patients who underwent PD between January 2019 and December 2023 were included. Propensity score matching was used to compare robotic PD with open and laparoscopic PD.RESULTSAmong 46,166 eligible PD cases, 1,371 were robotic. To ensure consistent surgical proficiency, the analysis included cases performed at institutions conducting ≥20 PDs annually (n=23,613). Following 1:1 matching, 1,248 robotic-open and 1,066 robotic-laparoscopic pairs were identified. Robotic PD was associated with a lower severe complication incidence than that with open (22.2% vs. 25.9%; odds ratio, 0.82; 95% confidence interval, 0.68-0.98; P=0.031) and laparoscopic PD (23.0% vs. 27.6%; odds ratio, 0.78; 95% confidence interval, 0.64-0.95; P=0.015). Robotic PD was also associated with a lower incidence of pancreatic fistula and shorter hospital stay, despite extended operative time. An increased incidence of deep venous thrombosis was observed in the robotic PD group.CONCLUSIONSIn this nationwide, Japanese credentialed setting, robotic PD was associated with improved short‑term outcomes compared with those of open and laparoscopic PD. As PD outcomes are influenced by surgeon/institutional experience and case complexity (tumor factors), these aspects should be carefully considered when selecting robotic PD.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"20 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145710824","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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