We 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. NRP 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. Using 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 (0-30min from circulatory death to cross-clamp) or NRP (30-180min). Propensity score matching (PSM) adjusted for donor and recipient differences. Kaplan-Meier methods assessed graft and patient survival. After PSM, NRP was associated with reduced DGF (30.3% vs. 49.7%), shorter hospital stay (median 4 vs. 5d), 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. NRP 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.

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.

To identify prognostic factors, including preoperative treatment duration, among patients who underwent conversion surgery (CS) for unresectable locally advanced pancreatic cancer (UR-LAPC). While CS has been increasingly adopted for UR-LAPC, optimal perioperative strategies remain controversial. This 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. Median 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. 29.7mo) and recurrence-free survival (RFS) (15.6 vs. 9.1mo) 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%). The 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.

To determine the incidence, timing, type, and indications for revisional surgery (defined as any operation performed after primary MBS up to 10y). Understanding 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. We 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. 145,193 patients (median age 42 (IQR 33-50) years 78.7% female) underwent primary MBS. Over a median 5.6y (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%). Incidence, type, and indication of revisional procedures differ from those of the primary procedure. These findings may guide patient decision-making and health system planning.

To establish international benchmark values for relevant outcome parameters in robotic Whipple. For 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. We 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. The 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 ≤4mm (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). This 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.

Objective: To 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 Data: Asymptomatic CAS may compromise hepatic and gastric perfusion after PD and TP, potentially increasing morbidity. The role of preoperative CAS detection and treatment remains unknown. Methods: International retrospective study at four high-volume centers in four countries (2018–2024). All preoperative CT imaging was re-assessed. CAS &gt;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. Results: Among 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 &lt;0.001), bile leak (OR 2.67, P =0.007), liver perfusion failure (OR 2.60, P &lt;0.001), and gastric ischemia (OR 11.29, P &lt;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. Conclusions: CAS 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.

To 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. Insurer-generated databases are widely used to study RAS outcomes, but inconsistent use of claims codes may lead to misclassification and biased estimates. This 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. Among 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. Sensitivity 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.