Exploring the landscape of minimally invasive pancreatic surgery: Progress, challenges, and future directions.

Therapeutic Advances in Pancreatic Cancer

Widespread implementation of the minimally invasive technique in pancreatic surgery has proven to be challenging. The aim of this study was to compare the perioperative outcomes of minimally invasive (laparoscopic and robotic) pancreatic surgery with open pancreatic surgery using data obtained from RCTs. A literature search was done using Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Web of Science; all available RCTs comparing minimally invasive pancreatic surgery and open pancreatic surgery in adults requiring elective distal pancreatectomy or partial pancreatoduodenectomy were included. Outcomes were mortality rate, general and pancreatic surgery specific morbidity rate, and length of hospital stay. Six RCTs with 984 patients were included; 99.0 per cent (486) of minimally invasive procedures were performed laparoscopically and 1.0 per cent (five) robotically. In minimally invasive pancreatic surgery, length of hospital stay (-1.3 days, -2 to -0.5, P = 0.001) and intraoperative blood loss (-137 ml, -182 to -92, P < 0.001) were reduced. In the subgroup analysis, reduction in length of hospital stay was only present for minimally invasive distal pancreatectomy (-2 days, -2.3 to -1.7, P < 0.001). A minimally invasive approach showed reductions in surgical site infections (OR 0.4, 0.1 to 0.96, P = 0.040) and intraoperative blood loss (-131 ml, -173 to -89, P < 0.001) with a 75 min longer duration of surgery (42 to 108 min, P < 0.001) only in partial pancreatoduodenectomy. No significant differences were found with regards to mortality rate and postoperative complications. This meta-analysis presents level 1 evidence of reduced length of hospital stay and intraoperative blood loss in minimally invasive pancreatic surgery compared with open pancreatic surgery. Morbidity rate and mortality rate were comparable, but longer duration of surgery in minimally invasive partial pancreatoduodenectomy hints that this technique in partial pancreatoduodenectomy is technically more challenging than in distal pancreatectomy.

Benefits of the volume-outcome association in pancreatic cancer surgery depend on patient level risk

Pancreatoduodenectomy is a challenging procedure for young general surgeons, and no benchmark outcomes are currently available for young surgeons who have independently performed pancreatoduodenectomies after completing resident training. This study aimed to identify the competency of a young surgeon in performing pancreatoduodenectomies, while ensuring patient safety, from the first case following certification by a General Surgical Board. A retrospective review of data from the university hospital was performed to assess quality outcomes of a young surgical attendant who performed 150 open pancreatoduodenectomies between July 13, 2006, and July 13, 2020. Primary benchmark outcomes were hospital morbidity, mortality, postoperative pancreatic fistula, postoperative hospital stay, and disease-free survival. All benchmark outcomes were achieved by the young surgeon. The 90-day mortality rate was 2.7%, and one patient expired in the hospital (0.7% in-hospital mortality). The overall morbidity rate was 34.7%. Postoperative pancreatic fistula grades B and C were observed in 5.3% and 0% of patients, respectively. The median postoperative hospital stay was 14days. The 1- and 3-year disease-free survival were 71.3% and 51.4%, respectively. Pancreatoduodenectomy requires good standards of care as it is associated with high morbidity and mortality. As only one surgeon could be included in this study, our benchmark outcomes must be compared with those of other institutions. The study was registered at Thai Clinical Trials Registry and approved by the United Nations (registration identification TCTR20220714002).

Surgery for pancreatic diseases is one of the most studied fields in general surgery and continues to evolve. This review focuses on recent advances in pancreatic surgery and summarizes the published research. Surgery for pancreatic diseases is an evolving field with a wide range of innovations. Especially, contributions by high-volume pancreas centers have greatly improved outcomes in pancreatic surgery. In chronic pancreatitis, recent studies demonstrate that early surgical treatment should be favored over repeated endoscopic interventions, and local organ-preserving resection techniques should be preferred over classic Whipple resection. Major advances have also been made on the diagnosis of pancreatic cystic lesions; however, the assessment of the current guidelines is still evolving. In pancreatic cancer, neoadjuvant treatment regimens appear to be promising, and extended pancreatic resections with vascular resection can now be offered with lower mortality and morbidity rates. Minimal-invasive laparoscopic and robotic surgical techniques are being used more frequently for the resection of pancreatic tumors and have seen major progress. In recent years, the outcome of patients undergoing pancreatic surgery improved due to better knowledge about the biology of the disease, more accurate diagnostic modalities, the application of organ-preserving surgical techniques in benign disorders and new advances in management strategies.

Introduction: Mortality rates after pancreaticoduodenectomy have decreased dramatically during the last two decades in high volume centers. However, despite a low mortality rate and improvements in perioperative care, morbidity rate is still high after pancreaticoduodenectomy. Studies defining the role of potential risk factors for the development of postoperative complications are few, and sometimes with conflicting results. There is need to identify potential risk factors for predicting complications after pancreatic resections. Aim: The aim of the present study was to assess the risk factors for morbidity after pancreatic resections, by utilizing a simple grading system and identify the factors affecting them. Material and Methods: This was a prospective study done in the Department of Surgical Gastroenterology between Feb 2007 to Jun 2009. All patients who underwent elective pancreatic surgeries were included in this study. Major Morbidity was defined as patients having grade III and above complications. The risk factors assessed were patient factors, disease factors, operative factors and postoperative factors. Risk factors were analyzed for morbidity and major morbidity separately. Results: One Hundred and Seven patients underwent elective pancreatic surgeries between Feb 2007 to Jun 2009. Pancreaticoduodenectomy was the commonest procedure. Three patients died after pancreatic surgeries. Mortality rate after pancreatic surgery was 2.8% (3/107) and that after Whipple’s procedure was 4.68% (3/64).In our study a total of 58 of 107 (54.2%) patients developed complications after pancreatic surgery. Major morbidity defined as Grade III or more complication was seen in 24.2% (26/107). Complications after Whipple’s procedure was seen in 49 of 64 (76%) patients. Major morbidity (Grade III and more) was seen in 22 of 64 patients (34.3%). All complications following pancreatic surgeries were graded. The mean postoperative duration was 12.4 days (6 – 47 days).The significant risk factors for morbidity after pancreatic surgery were soft pancreas (OR 5.988; p=.007), SGPT > 73 U/L (OR 3.623; p = .054), age > 50yrs (OR 3.254; p = .053), and absence of chronic pancreatitis (OR 4.363, p = .016).The significant factors for major morbidity were soft pancreas (OR 6.557, p = .005), hypertension (OR 5.803, p = .037) and BMI >25(OR 4.052, p = .05). Conclusions1. Independent factors predicting morbidity after pancreatic surgery were soft pancreas, age > 50yrs, SGPT > 73 U/L and absence of chronic pancreatitis.2. Independent factors predicting major morbidity after pancreatic surgery were soft pancreas, hypertension and BMI > 25.

SummaryThis literature review reflects the present evidence on minimally invasive pancreatic surgery, differentiating between distal pancreatic resection and pancreatoduodenectomy for pancreatic cancer. The review analyzed studies comparing minimally invasive and open pancreatic surgery in PubMed, the Cochrane Library, and the WHO Trial Register according to the following MeSH search strategy: MeSH items: pancreatic surgery, minimally invasive surgery, robotic surgery, laparoscopic surgery, pancreatoduodenectomy, and distal pancreatic resection. In systematic reviews and meta-analysis, minimally invasive distal pancreatectomy (MI-DP) has been shown to result in shorter hospital stays, less blood loss, and better quality of life than open distal resection (ODP) with similar morbidity and mortality. Meta-analyses have suggested similar oncological outcomes between the two approaches. Minimally invasive pancreatoduodenectomy (MI-PD) has been shown to offer advantages over open surgery, including shorter length of stay and less blood loss, by expert surgeons in several studies. However, these studies also reported longer operative times. As the procedure is technically demanding, only highly experienced pancreatic surgeons have performed MI-PD in most studies, so far limiting widespread recommendations. In addition, selection of cases for minimally invasive operations might currently influence the results. Registry studies from dedicated groups such as the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS) and randomized controlled trials currently recruiting (DIPLOMA‑1 and 2, DISPACT-2) will bring more reliable data in the coming years. In conclusion, both MI-DP and MI-PD have shown some advantages over open surgery in terms of shorter hospital stays and reduced blood loss, but their effectiveness in terms of oncological outcomes is uncertain due to limited evidence. The study highlights the need for further randomized controlled trials with larger sample sizes and registry studies to further evaluate the safety, efficacy, and oncological outcomes of minimally invasive pancreatic resections.

Is Improved Survival in Early-Stage Pancreatic Cancer Worth the Extra Cost at High-Volume Centers?

New knowledge about the nature of pancreatic diseases and the ability to perform more complex pancreatic surgical procedures have changed the indication for surgical treatment and permitted an introduction of organ-preserving surgical techniques. The rapid development in technological innovations has improved surgeons' techniques, and accumulation of surgeons' experiences improved the outcome after pancreatic surgery. Pancreatic cancer is one of the most devastating diseases known to mankind with the worst 5-year survival rate among neoplasms. Many surgeons created their own devices to improve the prognosis of such dismal disease, for example, no-touch approach, artery-first approach, or extensive intraoperative peritoneal lavage. By their endeavor, some lines of hope are being reported in several academic meetings. On the other hand, recent progress in diagnostic imaging procedures enables us to find various pancreatic lesions. Among them, slow growing tumors, such as intraductal papillary mucinous neoplasm (IPMN), mucinous and serous cystic neoplasms, solid pseudopapillary tumor, and pancreatic neuroendocrine tumor, are included. The presence of these rather low malignant tumors facilitated us to devise organ-preserving minimally invasive surgery, such as laparoscopic or robotically assisted pancreatectomy. Indeed, minimally invasive surgery has become widely accepted as a superior alternative to conventional open surgery for selected patients within the field of pancreatology. The first paper of this special issue addresses current and future intraoperative imaging modalities and their potential for improved tumor demarcation during pancreatic surgery. The second paper presents a new surgical technique of proximal subtotal pancreatectomy with splenic artery and vein resection; the so-called pancreaticoduodenectomy with splenic artery resection (PD-SAR). PD-SAR with preoperative chemoradiotherapy seems to be a promising surgical strategy for pancreatic ductal adenocarcinoma of head and/or body with invasion of the splenic artery, with regard to the balance between operative radicality and postoperative QOL. The third paper is on the Finnish binding (purse-string) pancreaticojejunal anastomosis (FBPJ), which was shown to reduce the risk for postoperative pancreatic fistula (POPF) after PD. In this paper, the efficacy of FBPJ after left pancreatectomy is discussed showing that FBPJ was not technically achievable in 72% of the cases and did not reduce the risk for POPF compared to the conventional hand-sewn closure. Therefore, FBPJ cannot be recommended for the routine closure of the pancreatic remnant after left pancreatectomy. The fourth paper describes paraduodenal pancreatitis (PP) which was proposed as a synonym for duodenal dystrophy (DD) and groove pancreatitis. Although conventional PD is the main surgical option for treatment of PP today, early diagnosis makes pancreas-preserving duodenal resection (PPDR) the treatment of choice for PP. Efficacy of PPDR provides proof that PP is an entity of the duodenum and not of paraduodenal origin. The fifth paper addresses the efficacy of combined endoscopic lithotomy (EL) plus extracorporeal shock wave lithotripsy (ESWL) and additional electrohydraulic lithotripsy (EHL) on pancreatic lithiasis. Combined EL plus ESWL therapy is regarded as the first treatment option. However, in cases where the combined therapy was not successful for stone clearance, SpyGlass guided EHL or X-ray guided EHL was effective. The sixth paper is a systematic review of randomized controlled trials (RCTs) dealing with surgical techniques in distal pancreatectomy. Management of the pancreatic remnant after distal pancreatectomy is still a matter of debate. New well designed and carefully conducted RCTs must be performed to establish the optimal strategy for pancreatic remnant management after distal pancreatectomy. The seventh paper presents the state of the art of pancreatic robotic surgery. With the current lack of evidence of any oncologic advantages, the cosmetic benefits offered by robotic surgery are not enough to justify its extensive use in cancer patients. In contrast, the safety of this procedure can justify the use of the robotic technique in patient with benign/low grade malignant tumors of the pancreas. The eighth paper describes the role of morphological and histological features of pancreatic stump in POPF occurrence after PD. Pancreatic texture, assessed by the surgeon, is a significant determining factor for pancreatic fistula and high grade pancreatic fistula and corresponds to pancreatic fibrosis grade. Moreover, careful consideration should be given to the larger pancreatic stumps, small Wirsung duct, wide pancreatic remnant mobilization, and duct decentralization on the stump anteroposterior axis. These morphological features also influence anastomosis failure. Finally, the last paper discusses the efficacy of splanchnicectomy to relieve pain in pancreatic cancer. Transhiatal bilateral splanchnicectomy achieves a certain denervation of splanchnic nerves, but it requires a laparotomy. Unilateral thoracoscopic splanchnicectomy is a minimally invasive procedure to cause definite denervation. Bilateral thoracoscopic splanchnicectomy is recommended for unsatisfactory cases or recurrent pain occurring after an initial unilateral splanchnicectomy. Masahiko Hirota Juhani Sand Ralf Segersvard Roberto Cirocchi

Entering the great unknown: Transition to academic practice

457 Background: The impact of hospital volume on the outcomes of cancer surgery has been well established. The present studies investigates how race/ethnicity influences the utilization of high-volume centers for hepatobiliary and pancreatic surgery. Methods: Patients that underwent surgery for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), ampullary adenocarcinoma (AC), or pancreatic ductal adenocarcinoma (PDAC) between 2006 and 2015 were identified from the National Cancer Data Base. Hospitals were divided into low- and high-volume centers based on the medium number of cancer surgeries per year. Multivariable logistic regression analyses predicting receipt of care at a low-volume center based on age, sex, race/ethnicity, comorbidities, insurance, income, travel distance, geographic location, urban/metro location, and tumor stage were performed. All analyses were performed separately by tumor type. Results: 8,962 patients with HCC, 2,119 with ICC, 3,973 with ECC, 5,125 with AC, and 25,231 with PDAC were identified. Non-Hispanic black patients were more likely to undergo resection for AC (vs. non-Hispanic white: AOR, 1.326; p = 0.0125) or PDAC (vs. non-Hispanic white: AOR, 1.187; p = 0.0002) at a low volume centers. Hispanic patients more often underwent surgery for ECC (vs. non-Hispanic white: AOR, 1.731; p &lt; 0.0001) or PDAC (vs. non-Hispanic white: 2.030; p &lt; 0.0001) cancer at a low-volume center. Patients of Asian descent were significantly less often treated for HCC at a low volume center (vs. non-Hispanic white: AOR, 0.644; p &lt; 0.0001) compared to non-Hispanic whites. Non-Hispanic black, Hispanic, or Asian race/ethnicity did not impact the likelihood of receiving care at a low volume center for any other tumor types. Conclusions: The results of this study suggest that race/ethnicity influences the likelihood of receiving care at a high-volume cancer center, even after controlling for other barriers to access to care, including insurance status, income and travel distance.

How high is a high-volume pancreatic surgery centre?

Working as a physician in the 21st century is clearly a different endeavor compared to 50 or 100 years ago. Automation and digitalization in every part of modern work have fundamentally changed the medical sciences and clinical environments. The rise of artificial intelligence (AI) and deep machine learning will likely transform patient care and medical research in the near future. A recent study published in Nature Medicine showed that AI was as effective as junior pediatricians in detecting common pediatric diseases.1 In surgery, it is still unclear how far AI will be able to refine, accelerate, or even replace surgeons in their specialized fields. Albert Einstein once said: “Imagination is more important than knowledge. For knowledge is limited […]”. In the context of this modern technological revolution, imagination, and constant reinvention as surgeons seem more important than before. To proactively design the future of surgery, it is essential that surgeons become key players in novel and high-quality research. Historically, surgeons have been combining both clinical and research activities since the 1800s, as suggested by the term “surgeon-scientist.” Unfortunately, the quality of surgical research seems to be declining. In the New England Journal of Medicine, the proportion of surgical papers on the overall number of publications in the journal has been dropping dramatically since 1952.2 Even more concerning is the apparent shortage of young surgeons to design and conduct original research.3 A recent Nature editorial urged more surgeons to perform basic science as a response to a report that indicated that the number of surgeon-scientists has dramatically been decreasing.4,5 These negative developments in surgical research seem hazardous and conflicting with the upcoming drastic changes and innovations required to maintain a high level of performance in modern academic surgery. Woldu et al, consequently asked whether the surgeon-scientist is a dying breed.6 In this context, it is particularly unfortunate that the interest in research seems to decrease among young surgeons, resulting in the “extinction of surgeon-scientists.”7 Recently, the Basic Science Committee of the Society of University Surgeons published a roadmap to encourage and guide the next generation of surgeon-scientists towards their academic career.8 Doing a research fellowship can be an essential step on this roadmap for aspiring surgeon-scientists. Here we aimed to highlight the benefits of a research fellowship and the advantages it holds for an academic surgical career. Whether the aim of the trainee is to become a surgeon-scientist or not, performing a research fellowship will impact and strengthen the 3 pillars of a modern academic surgeon: clinical practice, research, and teaching. Individual outcomes of formal research training among general surgeons show a strong association of research time during residency and objective markers of long-term academic success.9 Surgeons that performed 1 year of research training had higher h-indices and were more likely to obtain National Institutes of Health funding later in their careers.9 Bobian et al reported that otolaryngology surgeons who had research training were more likely to achieve higher academic ranks, whereas clinical fellowships did not show this association.10 It seems intuitive that surgeons who perform research training are more likely to thrive in academic environments. Dedicated research training promotes research productivity and output. Surgeons that performed a 1-year research training had more first-author publications during residency, which objectifies their commitment to research and their ability to lead a project to completion.9 Being “extracted” from a clinical setting and put into a scientific environment might be an initially stressful and frustrating experience for a trainee but can eventually promote a unique and precious “out-of-the-box” thinking attitude. Research fellowships are often the trainee's first interaction with research, especially in Europe where medical students do not usually perform an undergraduate degree before entering medical school. Such research experiences prepare young surgeons for their work in academic centers. Given the worldwide ongoing centralization into large academic centers, young surgeons will benefit from such preparation. Research training will teach young surgeons how to distinguish low-quality from high-quality scientific work, how to read, evaluate, and criticize the scientific literature and how to put different scientific methodologies into perspective. Moreover, this experience will teach surgeons how to plan and manage projects and to understand what it takes to complete a project within a certain timeframe. Some academic centers offer opportunities to enroll into programs leading to a secondary degree such as the Doctorate, Master of Science, Master of Public Health, Master of Science in Public Health, or Master of Business Administration. Residents involved in such programs with coursework would receive formal research training on various aspects of research, such as methodology, ethics, and grant writing The impact of a research fellowship on the clinical mindset and performance – although difficult to objectify – can be significant. Dedicated time for research is the ideal ground for boosting creativity that can later be applied to both scientific and clinical practice. The time and freedom required for creativity will render visionary and innovative strategic thinking. This time and freedom are not always available in a busy clinical environment. A more inquisitive mindset will help to shift one's perspective from the diagnosis and management of a disease towards questioning the underlying pathogenesis, facilitating bedside to bench research, as a first essential step to translate results from bench to bedside. Moreover, the extra time during training without calls and night shifts allows for new information to be processed and stored properly. To memorize knowledge and recall when necessary we need time. The opportunity to do exactly this and the freedom to take some time to reflect will likely enhance quality of life during those years.11 Throughout a research fellowship, trainees will be interacting with scientists, biologists, and students with different backgrounds. Whereas it is well-known that physicians, and even more so surgeons, tend to evolve in a tight community of similar personalities with similar backgrounds and training, a diverse research experience provides an ideal environment to improve communication skills. Clear communication is crucial in medicine. Patient outcomes depend on exact communication between physicians, nurses, patients, and caregivers. Also, good interaction can enhance work satisfaction among the involved professionals. It is essential for effective communication to express thoughts precisely and clearly. During research training, residents learn how to express their thoughts clearly and communicate complex data in an understandable way. For instance, scientific abstract and manuscript writing requires precise and concise summarizing of research findings. The preparation of a scientific presentation will train the resident to introduce their topic in a structured and logical way. Furthermore, learning how to present results from fundamental research will clearly enhance teaching skills. A scientific discussion educates trainees to defend their opinion but also to consider other valuable aspects. This enhances critical thinking skills which are important to acquire during research time. The constant interaction with other researchers fosters scientific thinking, that can be used for research design and hypothesis. The underlying scientific motto postulated by Karl Popper in his “Logic of Scientific Discovery” was the attempt to falsify one's own hypothesis. This constant reflection on hypothesis, results, and their interpretation will practice critical thinking, that in turn enables young surgeons to question dogmas in the clinical arena and position them to develop innovative strategies to challenge these dogmas. Another positive effect of formal research training is access to the international surgical community. Meetings at scientific conferences not only provide young academic surgeons with the state-of-the-art knowledge in their field, but also nourishes relationships with other academic surgeons worldwide. Once introduced to the international scientific community, young surgeons will become part of this community which can boost their intrinsic motivation. This can broaden their horizon as a surgeon and a person and put opinions into perspective. These benefits do not apply only to the trainee, but also to the institutions and training programs. The reputation of an academic center with high quality research will help attract future students, residents, and fellows, but also maintain a certain level of expertise and expectation, resulting in further expansion of the academic mission. These institutions should aim to develop a culture where scientific activity is the “gold-standard” and not the exception. Therefore, dedicated and protected research time is essential and young academics who undergo research training are more likely to support this approach. Lifelong personal relations with mentors within academic institutions can foster ongoing scientific and personal mentorship. It is widely accepted that one requirement for a successful career in medicine is mentorship.8 During a research fellowship it is likely that, one will find a lifelong mentor with substantial experience to support and guide the resident's trajectory in a surgical career. Moreover, extra time for personal development under directly mentored supervision will not only help to become a better researcher, but also enhance skills like public speaking, writing, innovative thinking, and networking. In line with this, Mansukhani et al argue that the years spent in the laboratory should be rebranded as personal development time.12 Whereas most countries are aiming towards standardized surgical training programs, a research fellowship is the ideal time for a resident to enjoy some freedom in training and self-management. This may lead to discover a new interest for yet unexplored domains during the often rigid and standardized clinical training. Although in the US and Canada research fellowships are often undertaken before or during general surgical residency, this is still rather an exception for trainees in other countries. In the US and Canada, research fellowships help applicants to obtain a position for residency or clinical fellowship which is likely why there is more request to do research during their training. In most European countries, where surgeons often times start a subspecialty without prior training in general surgery, there is no such incentive to conduct research training. Another aspect concerns the costs of a formal research training program for residents and their absence in clinical training during that time. Who will pay or compensate for it? We believe that if we want to strengthen and improve academic surgery, we have to advocate for funding for young academic surgeons to participate in established research programs. As academic surgeons, we have to participate in the decision making on the allocation of research funds and be present in the respective review committees. Also, access to dedicated research time has to be without barriers for all academic surgeons. Equity, diversity, and inclusion need to be promoted in terms of opportunities to collaborate or issues in balancing family and work life. If we want to enhance surgical research performance, we have to guarantee equal opportunity to recruit the best possible faculty into academic surgery. Now that the benefits of performing a research fellowship have been well established, another crucial question is the timing of such an experience. We believe that early research exposure is essential to develop the abovementioned skills necessary for high quality research. A formal training early during residency will not only enhance the interest for the specialty but will allow the establishment of a critical and scientific mindset that the resident will be able to benefit from during his/her residency. More than ever, it is now undeniable that surgeons should invest more in (basic) science – a formal research training such as a research fellowship is the best starting point to do exactly this.

手术切除迄今为止仍是胰腺癌唯一的潜在根治手段，但胰腺癌手术也是所有恶性肿瘤手术中围手术期风险最高、远期预后最差的手术之一，这对外科医生形成了巨大挑战。近年来，胰腺手术在高流量中心的集中化、手术技术的进步以及围手术期管理水平的提高等显著降低了胰腺手术的围手术期并发症发生率与死亡率，同时外科医生也开始尝试将腹腔镜以及机器人辅助手术等微创手段应用于胰腺癌根治术，以期降低手术对患者造成的创伤，进一步加速患者康复，提高患者的生活质量。已有多项研究对比了微创胰腺切除手术与传统开放手术的围手术期安全性，证实了微创胰腺切除手术的技术可行性，但微创手术对胰腺癌患者远期预后影响的研究仍然较少，胰腺癌根治术是否适合以微创的方式完成也仍存争议。因此，外科医生在对胰腺癌实施微创手术时应遵循整块切除与非接触等肿瘤学原则，并且应开展更多的对照研究来明确胰腺癌微创手术是否能使患者在长期生存方面获益。通过本综述，一方面希望能客观评价微创技术在胰腺癌根治术中的价值，另一方面也希望能尽量避免为了微创而微创、为了微创而违反肿瘤学原则现象的发生。

Background:Comprehensive preoperative risk stratification is essential for improving perioperative outcomes and guiding informed decisions in general surgery (GS). However, data scarcity remains a key challenge to developing robust, high-dimensional artificial intelligence (AI) models. To address this data barrier in surgical AI, transfer learning (TL) enables neural networks (NNs) to transfer and adapt knowledge from pretrained source models to new domains with critically limited data availability.Methods:This multicenter study included patients undergoing advanced GS at three tertiary centers between 2015 and 2023. Multiple large-scale source models for 90-day mortality prediction were trained on 85 preoperative parameters. Subsequently, organ-specific fine-tuning was performed for esophageal, liver, pancreatic, and colorectal surgery individually. TL models were benchmarked against standard ML models and conventional risk scores using the area under the receiver-operating characteristic curve (AUROC), precision–recall curve (AUPRC), and F1-score, including 95% confidence intervals. Feature analyses were performed for each NN to investigate and compare model interpretability.Results:14 922 patients (mean [SD] age: 58.5 [16.1] years) were included. Conventional ML achieved AUROCs of 0.75 (0.72–0.79; esophageal surgery), 0.80 (0.79–0.82; liver surgery), 0.73 (0.71–0.76; pancreatic surgery), and 0.92 (0.92–0.92; colorectal surgery) with corresponding AUPRCs reaching 0.37 (0.33–0.43), 0.30 (0.29–0.31), 0.29 (0.24–0.34), and 0.57 (0.56–0.58), respectively. TL significantly improved AUPRCs by 38% in esophageal (0.54 [0.51–0.58], P < 0.001), 14% in liver (0.34 [0.32–0.36], P < 0.001), and 8% in pancreatic surgery (0.31 [0.28–0.37], P < 0.001). Patient age and the Charlson Comorbidity Index (CCI) consistently emerged as the highest-weight features across all TL models. All NNs outperformed the American Society of Anesthesiologists Physical Status and CCI as conventional risk scores in predicting mortality.Conclusions:Machine learning outperforms conventional risk modeling in preoperative mortality prediction. TL can significantly enhance model performance in surgical domains with limited data availability, offering a promising approach to overcome persisting data constraints for AI in surgery.