Abstract Aim To investigate the effect of unplanned conversion to open surgery during laparoscopic pancreaticoduodenectomy on resection margins and complications. Method A systematic review and meta-analysis (proportion and comparison models) with meta-regression using random effects modelling compliant with PRISMA statement standards was conducted. All studies with a minimum sample size of 15 patients reporting conversion to open surgery in patients undergoing laparoscopic pancreaticoduodenectomy were included. The outcomes included R0 resection, Clavien-Dindo ≥ 3 complications, and 30-day mortality. Results A total of 44 studies comprising 6,108 patients were included. Conversion occurred in 11.3% (95% CI 9.1- 13.5). The reason for conversion was bleeding in 27.9% (16.3-39.5%), technical difficulties in 46.5% (95% CI 33.7-59.4), oncological concerns in 29.2% (95% CI 18.2- 40.2), and iatrogenic injuries in 7.7% (95% CI 3.4-12.1). Multivariable meta-regression analysis showed that conversion did not affect R0 resection (coefficient: -0.228, p=0.307), Clavien-Dindo ≥ 3 complications (coefficient: 0.129, p=0.609), and 30-day mortality (coefficient: -0.013, p=0.647). The outcomes were not affected by the reasons for conversion. Comparison meta-analysis showed that conversion does not affect R0 resection (RD: -0.07, 95% CI -0.17-0.03, p=0.18), Clavien-Dindo ≥ 3 complications (OR: 2.17, 95% CI 0.67-6.99, p=0.20), and 30-day mortality (RD: 0.02, 95% CI -0.04-0.07, p=0.57). Conclusions Unplanned conversion to open surgery, regardless of the reason for conversion, may not affect resection margins and complications in laparoscopic pancreaticoduodenectomy (moderate certainty). Conversion during laparoscopic pancreaticoduodenectomy should not be seen as a failure because it has no negative impact on outcomes; however, not converting when indicated will undoubtedly do.

IntroductionOpen pancreaticoduodenectomy (OPD) and laparoscopic pancreaticoduodenectomy (LPD) are the two main surgical approaches for treating pancreatic cancer.ObjectiveTo evaluate the cost-effectiveness of OPD and LPD in treating pancreatic ductal adenocarcinoma by establishing a Markov Model.MethodsPatients with pancreatic ductal adenocarcinoma who staged at I-III undergone OPD or LPD were retrospectively included from March 2017 to December 2020. Patients were followed up by telephone until June 2024. A Markov Model was established to simulate disease progression after 120 cycles by including survival data and average hospitalization costs.ResultsTwo hundred patients were included, 100 for OPD group and the other 100 for LPD group. The results indicated that after 10 years of model operation, the LPD group had an increased cost of 13,175.31 yuan compared to the OPD group, with an incremental effect of 0.063 per quality-adjusted life years (QALY). It also showed that the incremental cost-effectiveness ratio value was ¥205,864.22per QALY, which was less than willing to pay (¥268,074.00).ConclusionThis study is the first to analyze the cost-effectiveness of OPD versus LPD in PDAC. The study indicated that LPD remains an acceptable operation with certain cost-effectiveness for pancreatic cancer patients. However, due to the low survival rates and the fact that LPD is a highly technique-dependent operation for pancreatic cancer, surgeons should keep cautious of the choice between the OPD and LPD based on the patient’s expectation and financial situation.

To evaluate real-world clinical outcomes of robotic pancreaticoduodenectomy (PD) versus open and laparoscopic PD in a nationwide cohort. While 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. Data 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. Among 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. In 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.

BackgroundPeritoneal dialysis (PD) is one of the relatively safe and effective renal replacement therapies for patients with end-stage renal disease (ESRD). There are three main types of PD catheter insertion procedures: open surgery, laparoscopic surgery, and percutaneous insertion. Currently, open surgery is most commonly used in clinical practice, although some hospitals have adopted laparoscopic and percutaneous insertion methods. However, there is still a lack of large-scale studies comparing percutaneous and laparoscopic catheter placement. This study aims to collect and synthesize existing literature data, analyze complications related to PD catheter insertion, and determine the optimal catheter placement method.MethodsThis Meta-analysis has been registered on the PROSPERO platform (CRD42024509930). Articles published in EMBASE, PubMed, Web of Science, and CNKI were retrieved, statistically analyzed, and reviewed. The statistical software Review Manager version 5.4.1 was used for data analysis.ResultsA total of nine studies on surgical outcomes and complications were included. The article types included one randomized controlled trial (RCT), one prospective study, and seven retrospective studies. The methodological quality of the 8 included non-randomized studies was assessed using the Newcastle-Ottawa Scale (NOS). The average score was 7.4 points (range: 6 to 8), indicating an overall high study quality. According to existing literature, laparoscopic PD catheter insertion may reduce postoperative bleeding risk but is associated with a longer surgical duration. Additionally, there were no statistically significant differences between laparoscopic and percutaneous catheter insertion methods in terms of the length of hospital stays, early and late complications—including peritonitis, exit-site infections, catheter malfunction and failure, hernia, and dialysate leakage.ConclusionData analysis indicates that the clinical outcomes of laparoscopic and percutaneous PD catheter insertion are similar. However, large-scale, multicenter studies are still needed to further validate these findings.Clinical trial numberNot applicable.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12882-025-04597-z.

Introduction: Duct-to-mucosa pancreaticojejunostomy (PJ) is a widely accepted. However, it is difficult to implement during laparoscopic surgery, particularly for a small main pancreatic duct (MPD). We attempted to perform PJ without suturing the main pancreatic duct (WSMPD) and examined its safety and feasibility. Materials and Methods: We retrospectively reviewed 126 patients who underwent laparoscopic pancreaticoduodenectomy (LPD) between 2019 and 2024. Among them, 64 patients underwent Blumgart PJ and 62 underwent WSMPD PJ. The patients’ demographics and short-term clinical safety were examined. Results: After 1:1 PSM, the WSMPD group had significantly shorter operation and PJ durations and higher biochemical leakage than those in the Blumgart group. However, no significant differences were observed in other postoperative complications between the groups. Furthermore, the operation and PJ durations were shorter in the WSMPD group than in the Blumgart group, regardless of the MPD size (> 3 mm or ≤ 3 mm). In the Blumgart group, patients with MPD ≤ 3 mm had longer PJ duration and hospital stay as well as higher hospital expenses, incidence of B + C grade pancreatic fistula, and incidence of abdominal infection than those with MPD > 3 mm. In the WSMPD group, no significant differences were observed among the patients. Conclusions: WSMPD PJ is a safe, effective, and easy-to-perform method that simplifies LPD procedures. It is particularly suitable for cases involving small MPDs.

Predictive factors of postoperative ascites after laparoscopic pancreaticoduodenectomy for periampullary carcinoma.

From totally laparoscopic to pure robotic pancreatoduodenectomy: A propensity score matching analysis of a single-center experience.

Assessment of surgical invasiveness in hepatobiliary and pancreatic surgeries by quantifying intraoperative energy expenditure: A comparison between laparoscopic and open surgery.

Minimally invasive pancreaticoduodenectomy (MIPD) is used more commonly, but this surge is mostly based on observational data. This meta-analysis aimed to compare the short-term outcomes between MIPD and open pancreaticoduodenectomy (OPD) using data collected from randomized controlled trials (RCTs). We searched PubMed, Cochrane Library, Embase, and Web of Science databases for RCTs comparing MIPD and OPD published before December 10, 2024. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. A total of eight studies were included, including two studies evaluating robotic PD (RPD) and six studies evaluating laparoscopic PD (LPD). Although MIPD was associated with a longer operative time (MD, 49.90min; 95% CI, 27.53, 72.27, P < 0.0001), patients may benefit from reduced blood loss (MD, -96.55mL; 95% CI, -145.25, -47.86, P = 0.0001), and shorter length of stay (MD, -1.01days; 95% CI, -1.74, -0.27, P = 0.007). There were no significant differences observed in readmission (RR, 1.04), 90-day mortality (RR, 1.13), overall morbidity (RR, 0.99), major complications (RR, 1.04), postoperative pancreatic fistula (RR, 0.98), postpancreatectomy hemorrhage (RR, 0.98), delayed gastric emptying (RR, 0.93), number of harvested lymph nodes (MD, 0.39), and R0 resection (RR, 1.00) between the groups. In addition, the subgroup results showed that both RPD (MD, -90.54mL; 95% CI, -125.39, -55.69, P < 0.00001) and LPD (MD, -100.64mL; 95% CI, -163.23, -38.06, P = 0.002) reduced the intraoperative blood loss. Although some short-term outcomes were similar between MIPD and OPD, MIPD exhibited reduced intraoperative blood loss and shorter hospital stay. In the future, MIPD may become a safe and effective alternative to OPD.

ABSTRACTThis case reports a rare co‐occurrence of pancreatic intraductal papillary mucinous neoplasm with invasive carcinoma and ampullary neuroendocrine tumor. Laparoscopic pancreaticoduodenectomy was done. No recurrence/metastasis in 12‐month follow‐up, though both tumors had lymph node metastasis, warranting attention to timely biopsy.

We aimed to investigate the effect of unplanned conversion to open surgery during laparoscopic pancreaticoduodenectomy on resection margins and complications. A systematic review and meta-analysis (proportion and comparison models) with meta-regression using random-effects modelling compliant with PRISMA statement standards was conducted. All studies with a minimum sample size of 15 patients reporting conversion to open surgery in patients undergoing laparoscopic pancreaticoduodenectomy were included. The outcomes included R0 resection, Clavien-Dindo ≥3 complications, and 30-day mortality. A total of 44 studies comprising 6,108 patients were included. Conversion occurred in 11.3% (95% confidence interval (CI) 9.1-13.5). The reason for conversion was bleeding in 27.9% (16.3-39.5%), technical difficulties in 46.5% (95% CI 33.7-59.4), oncological concerns in 29.2% (95% CI 18.2-40.2) and iatrogenic injuries in 7.7% (95% CI 3.4-12.1). Multivariable meta-regression analysis showed that conversion did not affect R0 resection (coefficient: -0.228, p=0.307), Clavien-Dindo ≥3 complications (coefficient: 0.129, p=0.609) and 30-day mortality (coefficient: -0.013, p=0.647). The outcomes were not affected by the reasons for conversion. Comparison meta-analysis showed that conversion does not affect R0 resection (risk difference (RD): -0.07, 95% CI -0.17-0.03, p=0.18), Clavien-Dindo ≥3 complications (odds ratio: 2.17, 95% CI 0.67-6.99, p=0.20) and 30-day mortality (RD: 0.02, 95% CI -0.04-0.07, p=0.57). Unplanned conversion to open surgery, regardless of the reason for conversion, may not affect resection margins and complications in laparoscopic pancreaticoduodenectomy (moderate certainty). Conversion during laparoscopic pancreaticoduodenectomy should not be seen as a failure because it has no negative impact on outcomes; however, not converting when indicated will undoubtedly have negative impact.

Cumulative sum analysis after the initial learning curve for laparoscopic pancreaticoduodenectomy: Does one continue to learn?

Laparoscopic pancreaticoduodenectomy(LPD) poses a high risk of intraoperative bleeding due to the complex anatomy and rich blood supply in the pancreatic head region. This paper innovatively proposes a blood flow control technique system for LPD, adopting a strategy of "priority devascularization and pre-blocking".By first addressing the peripheral collateral blood supply and the gastroduodenal artery, and then performing dual-system pre-blocking, the dorsal pancreatic artery and the inferior pancreaticoduodenal artery are treated in situ through a combined middle and left posterior approach. This progressive blood flow control method enhances surgical safety and oncological radicality, offering a new paradigm for the development of minimally invasive pancreatic surgery.

Background/Objectives: Textbook outcome (TO) is a composite quality measure in surgery, but few studies have compared TO between robotic pancreaticoduodenectomy (RPD) and laparoscopic pancreaticoduodenectomy (LPD). This study aimed to evaluate and compare TO following RPD and LPD for periampullary neoplasms. Methods: We retrospectively analyzed 322 patients who underwent minimally invasive PD between 2010 and 2023 (RPD, n = 60; LPD, n = 262). LPD was first introduced in 2004, but only cases performed since 2010 were included, while RPD has been performed since 2019. Propensity score matching (1:2) yielded 48 RPD and 96 LPD patients. TO was defined as the absence of pancreatic fistula, bile leak, post-pancreatectomy hemorrhage, severe complications (Clavien-Dindo ≥ III), readmission, and in-hospital or 30-day mortality. Results: In the entire cohort, 240 of 322 patients (74.5%) achieved TO. After matching, TO rates were 64.6% in RPD and 76.9% in LPD (p = 0.656). Perioperative outcomes, including operative time, blood loss, transfusion, hospital stay, and major complications, were comparable, although RPD showed a higher incidence of hemorrhage (p = 0.032). Multivariate analysis identified body mass index < 25 kg/m2 as an independent predictor of achieving TO (OR 3.13, p = 0.008). Conclusions: RPD and LPD achieved comparable textbook outcomes in periampullary surgery. Both approaches are feasible when performed by experienced surgeons, but larger studies with long-term follow-up are needed to validate these findings.

BackgroundThe optimal surgical approach for large benign or low-grade malignant pancreatic tumors is controversial. The objective of this study was to evaluate the safety and feasibility of laparoscopic enucleation (LapEN) for large pancreatic tumors (≥4 cm).MethodsPatients who met the inclusion criteria at Qilu Hospital of Shandong University from January 2015 to May 2022 were retrospectively analyzed. First, the safety and feasibility of LapEN procedure were evaluated based on tumor diameter (≥4 cm or not). And then, we further compared the efficacy between LapEN and standard pancreatectomy [laparoscopic pancreaticoduodenectomy (LPD)/ laparoscopic distal pancreatectomy (LDP)] in patients with large tumors (≥4 cm).ResultsCompared with patients with small tumors who underwent LapEN, there was no significant difference in rates of perioperative adverse events and postoperative complications in patients with large tumors who underwent LapEN, only postoperative hospital stays were prolonged. Among patients with large pancreatic tumors, comparison with standard pancreatectomy, LapEN achieved shorter operative time [(LapEN vs. LPD: 160.0 ± 41.4vs 396.8 ± 92.4 min, p < 0.001); (LapEN vs. LDP: 132.5 ± 53.0 vs. 223.1 ± 67.7 min, p < 0.001)] and less blood loss {[LapEN vs. LPD: 50 mL (range, 10–400 mL) vs. 300 mL (range, 50–1,000 mL), p < 0.001]; [LapEN vs. LDP: 40 mL (range, 5–300 mL) vs. 150 mL (range, 20–1,000 mL), p = 0.001]}. Particularly for large pancreatic head tumors, LapEN was superior to LPD in other terms of conversion rate, postoperative hospital stays, duration of fasting, pain score, and red blood cell transfusion rate.ConclusionLapEN is a safe and feasible treatment option for large benign or low-grade malignant pancreatic tumors.

Laparoscopic pancreaticoduodenectomy (LPD) has become a widely adopted surgical approach for treating pancreatic head cancer. Traditional open pancreaticoduodenectomy (OPD) is associated with significant surgical trauma, with postoperative hospital stays often exceeding 2 weeks. In contrast, LPD presents higher surgical risks due to the lack of standardized protocols, particularly posing challenges in minimally invasive resection and anastomosis. In addition, the optimal extent of lymphatic and neural dissection in pancreatic head cancer remains controversial and continues to be actively debated. To address these challenges in traditional pancreatic cancer treatment, we developed a modular surgical approach and a dual-surgeon model to systematize laparoscopic pancreatic surgery. Our novel Laparoscopic Programmatic Neurolymphatic Radical Pancreaticoduodenectomy (LPNRPD) technique not only ensures surgical safety but is also user-friendly, making it particularly suitable for laparoscopic surgery beginners. For radical resection of pancreatic head cancer, we propose that complete dissection of the peripancreatic neural plexus is critical for achieving R0 resection. Through multicenter RCT studies, we established standardized protocols for radical neurolymphatic dissection tailored to different subtypes of pancreatic cancer. For patients with resectable pancreatic head cancer (preoperative CA19-9 < 200 U/mL, no vascular invasion), we recommend the LPNRPD strategy. However, the successful implementation of LPNRPD heavily relies on the surgeon's skill and expertise. This article provides a comprehensive overview of the techniques for performing LPNRPD, emphasizing its safety, reproducibility, and applicability in the context of pancreatic head cancer treatment.

Laparoscopic pancreaticoduodenectomy (LPD) is considered the Mount Everest surgery in laparoscopic surgery due to its complex surgical process, high technical requirements, and high incidence of complications. Pancreatic leakage is a common complication of LPD, and severe pancreatic leakage can endanger the patient's life. The occurrence of pancreatic leakage is influenced by multiple factors, and the choice of pancreaticointestinal anastomosis method and the quality of anastomosis are the only controllable factors during surgery. In order to reduce the occurrence of pancreatic leakage, especially severe pancreatic leakage (grade B/C), pancreatic surgeons have continuously improved and innovated the LPD pancreaticointestinal anastomosis method in recent years. Pancreatic duct jejunal mucosal anastomosis is one of the most widely used pancreatic intestinal anastomosis procedures and has been internationally recognized. Due to the unique perspective, operational limitations, and lack of tactile sensation of laparoscopic suturing, it is difficult to complete the anastomosis of the pancreatic duct and jejunal mucosa under laparoscopy for patients with small pancreatic ducts (< 3 mm) and soft and fragile pancreatic tissue. Our team innovatively applied laparoscopic reverse needle continuous suturing of the pancreatic duct to the jejunal mucosa for pancreas-intestine anastomosis. Compared with the traditional laparoscopic pancreatic duct to jejunal mucosa for pancreas intestine anastomosis, it is more in line with the laparoscopic operation perspective, reduces the difficulty of suturing, shortens the anastomosis time, improves the quality of anastomosis, and reduces the occurrence of pancreatic leakage. Moreover, it can reduce the consumption of sutures and minimize the number of knots.

PurposeThis study aims to investigate the risk factors for postoperative intraluminal hemorrhage (IPPH) after laparoscopic pancreaticoduodenectomy (LPD), with the aim of enhancing clinical management through the exploration and development of a risk prediction model with those factors.MethodThe clinical data of 326 hospitalized patients between January 2020 and August 2023 who underwent LPD for malignancies were retrospectively selected. The data consisted of general conditions, comorbidities, preoperative treatments, laboratory tests, and postoperative complications. We explored the risk factors associated with postoperative intraluminal hemorrhage using univariate and multivariate logistic regression analyses and developed a predictive model of IPPH after LPD.ResultsThe incidence of IPPH in LPD patients was 7.06%. Advanced age (OR = 1.065, 95% CI = 1.001–1.133, P = 0.045), low fibrinogen level (OR = 0.485, 95% CI = 0.242–0.972, P = 0.041), low albumin level (OR = 0.840, 95% CI = 0.739–0.956, P = 0.008), clinically relevant postoperative pancreatic fistula (CR POPF, OR = 4.300, 95% CI = 1.347–13.722, P = 0.014), and intra-abdominal infection (IAI, OR = 6.347, 95% CI = 1.454–27.716, P = 0.014) were associated with an increased incidence of IPPH. A nomogram was developed and validated with a specificity of 82.2%, a sensitivity of 82.6%, and an AUC value of 0.861 (95% CI 0.783–0.939).ConclusionRisk factors for IPPH include advanced age, low fibrinogen levels, low albumin levels, CR POPF, and IAI. These risk factors were used to develop a nomogram for identifying patients at high risk of IPPH, allowing for targeted interventions to address modifiable risk factors promptly and improve patient outcomes.

This meta-analysis compares outcomes of pancreaticoduodenectomy (PD) using open (OPD), robotic (RPD), and laparoscopic (LPD) techniques in patients with and without obesity and resectable pancreatic cancer. Thirteen observational studies evaluating 30-day mortality and postoperative complications in patients that underwent PD were included. Outcomes included mortality, major complications (Clavien-Dindo classification), and specific surgical complications: postoperative pancreatic fistula (POPF), post-PD hemorrhage (PPH), delayed gastric emptying (DGE), and surgical site infections (SSI). Patients with obesity had higher 30-day mortality rates (2.42% vs. 1.63%; OR: 1.68, 95% CI: 1.35-2.08, p < 0.00001, I² = 0%) and major complications (23.3% vs. 17.12%; OR: 1.77, 95% CI: 1.27-2.46, p = 0.0007, I² = 52%) than patients without obesity. Obesity also increased the risk of POPF (21.9% vs. 13.76%; OR: 2.04, 95% CI: 1.69-2.46, p < 0.00001, I² = 26%), PPH (7.31% vs. 6.26%; OR: 1.44, 95% CI: 1.07-1.94, p = 0.02, I² = 0%), and DGE (20.23% vs. 15.5%; OR: 1.98, 95% CI: 1.3-3.03, p < 0.00001, I² = 89%). SSI risk trended higher in patients with obesity but was not statistically significant (28.17% vs. 20.39%; OR: 1.80, 95% CI: 0.93-3.5, p = 0.08, I² = 90%). Among surgical techniques, patients with obesity who underwent OPD had higher risks of 30-day mortality (OR: 1.59, 95% CI: 1.26-2.00, p < .0001), major complications (OR 1.63, 95% CI 1.17-2.28, p = 0.004), and POPF (OR 1.98, 95% CI 1.59-2.47, p < 0.00001) than patients without obesity. In the RPD group, obesity increased the risk of 30-day mortality (OR: 2.68, 95% CI: 1.12-6.39, p = 0.03) and POPF (OR 3.32, 95% CI 1.68-6.57, p = 0.0006). In LPD, obesity was associated with a higher risk of POPF (OR 2.06, 95%CI 1.69-3.32, p = 0.003). Patients with obesity undergoing PD are at increased risk for 30-day mortality and major complications. OPD carries the highest overall risk, while RPD and LPD are linked to a greater POPF risk. These findings highlight the need for careful perioperative management in this high-risk population.

Laparoscopic pancreaticoduodenectomy (LPD) is a minimally invasive approach for pancreatic head and ampullary tumours, with pancreaticojejunostomy (PJ) critically influencing post-operative outcomes. This study aimed to compare a modified continuous single-layer PJ technique with the conventional two-layer method in LPD. A retrospective cohort study of 22 patients undergoing LPD compared the surgical outcomes between the modified group (n = 12) and the conventional group (n = 10). Baseline characteristics were well-matched between the two groups. The modified group demonstrated significantly shorter anastomosis time (19.08 vs. 23.1 min, P < 0.001) and lower abdominal infection rates (0 vs. 3 cases, P = 0.041). No significant differences were observed in clinically relevant post-operative pancreatic fistula or bleeding. Conclusively, the modified continuous single-layer PJ technique appears safe and feasible, offering efficiency advantages without compromising short-term outcomes. However, large-scale randomised controlled trials are warranted to validate safety, efficacy and long-term prognostic implications.