Between 2002 and 2013, we performed pancreatoduodenectomy (PD) with combined resection of the superior mesenteric artery (SMA) (PD-SMAR) to treat locally advanced pancreatic head cancer (PHC). Since 2011, we have performed PD with circumferential lymph node dissection along the SMA (PD-CLDS), in which we dissected lymph nodes all around the SMA for thorough lymph node dissection (LND) along the SMA. In this study, we examined the status of lymph node metastasis and the efficacy of LND along the SMA. In the first study, 22 patients with PHC who underwent PD-SMAR were enrolled. We examined the location of lymph nodes along the SMA and the incidence of metastasis. In the second study, we examined the incidence of metastasis at each lymph node station and evaluated the efficacy of LND along the SMA with 103 patients who underwent PD-CLDS. Lymph nodes along the SMA were classified into five basins using PD-SMAR specimens. Lymph nodes along the SMA were the most frequent station of metastasis, which showed the highest efficacy of LND in PD-CLDS. Lymph nodes along the SMA are a frequent site of metastasis and LND along the SMA demonstrates high efficacy among the regional lymph nodes in PHC.

Introduction:Common complications after endoscopic retrograde cholangiopancreatography (ERCP) include acute pancreatitis, gastrointestinal perforation or bleeding, while splenic artery rupture and bleeding is a very rare complication.Main symptoms:This study reports a case of splenic artery rupture and bleeding after ERCP, providing reference experience for clinicians. This article describes the case of a 67-year-old patient who underwent ERCP to alleviate jaundice associated with pancreatic head cancer. During the procedure, the patient experienced unexpected hemorrhagic shock.Diagnoses, interventions, and outcome:The shock was later confirmed as distal splenic artery (short gastric artery) bleeding by digital subtraction angiography, without splenic capsule tearing or subcapsular hematoma. Distal splenic artery branch embolization was performed immediately to avoid splenectomy, and satisfactory results were achieved.Conclusion:Splenic artery bleeding is an unexpected and extremely rare complication after ERCP and distal splenic artery branch embolization with digital subtraction angiography is a possible treatment approach. This case provides physicians with valuable experience, highlighting the importance of being highly suspicious of such rare complications, and discussing the possible causes and treatment methods for splenic injury following ERCP.

Pancreatic cancer (PC) is a refractory malignancy with a dismal prognosis. For unresectable PC, gemcitabine plus nab-paclitaxel (GnP) is widely used as first-line chemotherapy. During treatment, patients may require unplanned hospitalization (UPH) due to tumor progression, biliary obstruction, or chemotherapy-related adverse events. Although UPH during chemotherapy may be linked to poorer survival, its prognostic impact as a time-dependent clinical event during active treatment has not been empirically evaluated in unresectable PC. We investigated the prognostic impact of UPH occurring during first-line GnP therapy. To clarify the association between UPH during first-line GnP and overall survival (OS). We retrospectively analyzed 189 patients with histologically confirmed unresectable PC who received first-line GnP at our institution between February 2016 and February 2023. The occurrence of UPH during GnP and the reason for the first UPH were categorized. Associations with OS were assessed using the Kaplan-Meier method and Cox proportional hazards models, including a time-varying covariate (TVC) analysis. Risk factors for UPH were examined with logistic regression. UPH occurred in 76 patients (40.2%) during GnP. Pancreatic head tumors and pre-treatment biliary drainage were significantly more frequent in the UPH group. Median OS was 10.88 months in the UPH group versus 19.23 months in the non-UPH group; UPH was a significant adverse prognostic factor (hazard ratio [HR] 1.97, p < 0.01). In multivariable analysis incorporating a TVC, UPH remained an independent predictor of worse prognosis (HR 3.02, p < 0.01). Reasons for first UPH were progression (n = 28), recurrent biliary obstruction (RBO; n = 26), GnP-related adverse event (AE; n = 16), and other (n = 6). Hospitalization due to progression or RBO was associated with poorer survival. Pancreatic head location was identified as a risk factor for UPH. UPH during first-line GnP is an independent adverse prognostic factor in patients with unresectable PC, even after accounting for TVC. In pancreatic head cancer, closer monitoring for biliary and obstructive complications may be particularly important during treatment.

Early postoperative recurrence of pancreatic head cancer (PHC) severely affects prognosis. We developed and validated a machine learning (ML)-based model incorporating a novel inflammatory composite index to predict early recurrence in PHC patients. We retrospectively analyzed 526 PHC patients who underwent pancreaticoduodenectomy at Fudan University Shanghai Cancer Center (2021-2022). Patients were randomly divided into training (70%) and test (30%) sets. Preoperative clinical, laboratory (ALI, PNI, SIRI), and pathological data were collected. Ten machine learning models were developed and evaluated using AUC, DCA, calibration, and precision-recall curves. The Random Forest model showed the best performance and was interpreted with SHAP. Of the 526 patients, 164 (31.2%) developed recurrence or metastasis within one year. Multivariate logistic regression identified ALI, CA199, tumor differentiation, capsule integrity, and nerve invasion as independent risk factors. The RF model demonstrated excellent performance, with an AUC of 0.992 in the training set and 0.783 in the test set. SHAP analysis highlighted CA199, ALI, tumor differentiation, capsule status, and nerve invasion as key predictors. We developed and validated an RF-based predictive model incorporating a novel inflammatory index for assessing early recurrence risk in PHC patients, which may aid individualized postoperative management.

ABSTRACTBackgroundPancreatic cancer (PC) remains one of the most lethal malignancies worldwide, characterized by late‐stage diagnosis and a poor prognosis. This study explores the clinical, biochemical, and gut microbiota differences between PC patients and healthy controls (CTRL), as well as between subgroups of PC patients with pancreatic head cancer (PHC) and pancreatic body‐tail cancer (PBTC).MethodsA total of 72 PC patients and 37 CTRL subjects were included, with further stratification of PC patients into 45 PHC and 27 PBTC cases. Clinical and biochemical data were collected. Gut microbiota was analyzed by 16S rRNA gene sequencing. Alpha‐diversity indices, Firmicutes/Bacteroidetes ratio and taxonomic composition were evaluated and compared in all the experimental group. Correlation analyses were performed between specific bacterial taxa and biochemical markers and a Random Forest algorithm was applied to identify taxa discriminating PC from CTRL and PHC from PBTC.ResultsClinical and biochemical data revealed significant heterogeneity between groups, with PHC patients exhibiting higher markers of inflammation and liver dysfunction, while PBTC patients showed relatively preserved physiological status. Gut microbiota analysis revealed significant dysbiosis in PC patients compared to CTRL. Alpha‐diversity indices demonstrated reduced species evenness in PC patients, while the Firmicutes/Bacteroidetes ratio was significantly lower. Taxonomic composition analysis indicated enrichment of pro‐inflammatory taxa and depletion of beneficial SCFA‐producing genera. However, subgroup comparisons revealed distinct microbial profiles, with PHC patients enriched in taxa associated with localized inflammation and PBTCs showing higher levels of anti‐inflammatory and SCFA‐producing bacteria. A correlation analysis linked specific bacteria to markers of liver dysfunction and systemic inflammation, such as GGT, ALP, and ESR, while SCFA‐producing taxa correlated negatively with inflammatory markers. A Random Forest algorithm identified key microbial taxa discriminating PC patients from CTRL and PHC from PBTC.ConclusionsThese findings highlight the interplay between microbiota composition, tumor localization, and systemic inflammation, showing a potential for microbiota‐based diagnostics and interventions in PC.

BackgroundGiven the growing interest in the influence of lymph node metastasis on the prognosis of patients diagnosed with pancreatic head cancer (PHC). This study aims to evaluate the ability of current four nodal staging systems predicting long-term outcomes and develop a machine learning model for predicting the prognosis of patients with resectable PHC.Materials and methodsParticipants with PHC were sourced from the Surveillance, Epidemiology, and End Results (SEER) database and allocated at random in a 7:3 ratio to training and internal validation cohort. External validation in a large-sample, multicenter cohort collected from three Chinese institutions was performed to verified the robustness of the optimal nodal staging system and predictive model. The concordance index (C-index), Akaike information criterion (AIC) and area under the curve (AUC) were calculated to evaluate the predictive capability and discrimination of different nodal staging systems. The machine learning procedures based procedure and Cox regression analysis were implemented for identification of the prognostic factors and construction of predictive model. The calibration curves, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) and decision curve analysis (DCA) were using to assess predictive accuracy and clinical benefits of the predictive model.ResultsAll four nodal staging systems were independent prognostic factors for overall survival (OS). The log odds of lymph node ratio (LODDS) were verified as the optimal nodal staging system with highest C-index and AUCs, and lowest AICs compared to others, and has better predictive capability than others both in patients with < 12 and ≥ 12 retrieval lymph nodes (RLNs). Then, a predictive model including T stage, tumor differentiation, chemotherapy, and LODDS was developed and validated. This model had a higher C-index and AUCs than the AJCC staging system. The NRI, IDI, and DCA analysis also indicated that present model had good predictive capability and clinical utility.ConclusionThe nodal staging system LODDS is the optimal prognostic factor for OS in resectable PHC. It could effectively predict OS for resectable PHC patients without considering the numbers of RLN. The machine learning model could effectively predict OS for patients with resectable PHC.

Efficacy and safety of TRIANGLE operation for pancreatic head and body cancer: a systematic review and meta-analysis.

An 86-year-old woman was referred from another hospital for gemcitabine monotherapy for locally advanced pancreatic head cancer. After 8 courses of gemcitabine monotherapy, follow CT showed partial response, and biliary metallic stent which had been placed 8 months ago displaced into the duodenum. An upper gastrointestinal endoscopy was performed and the stent was retrieved. There has been no subsequent elevation in hepatic and biliary enzymes, and she is currently under observation without re-stenting. There have been reports of displaced biliary stents causing gastrointestinal perforation and intestinal obstruction. For cases where chemotherapy is effective and the placement duration of the bile duct stent is prolonged, it is necessary to increase the frequency of abdominal X-rays to monitor the dislocation of the bile duct stent carefully.

This study evaluated the feasibility and outcomes of surgical treatment for metachronous periampullary carcinoma following curative resection of primary extrahepatic bile duct cancer. A retrospective review was conducted of seven patients who underwent pancreaticoduodenectomy (PD) for metachronous periampullary cancer after prior curative surgery for extrahepatic bile duct cancer. The mean age at the second surgery was 66.7 years (range, 43-81 years). Initial malignancies included three hilar cholangiocarcinomas, one middle bile duct cancer, and three gallbladder cancers. Subsequent primary tumors consisted of three distal bile duct cancers, three pancreatic head cancers, and one duodenal cancer. The mean interval between the first and second cancers was 47 months (range, 13-121 months). No perioperative deaths occurred. Postoperative complications developed in three patients (42.9%): chyle leakage (Clavien-Dindo grade II) in two (28.6%) and a grade C postoperative pancreatic fistula requiring reoperation (grade IIIb) in one (14.3%). Both chyle leaks were managed conservatively. During follow-up, four patients died of recurrence at 5, 12, 19, and 24 months postoperatively. One patient underwent video-assisted thoracoscopic surgery for pulmonary metastasis 2 months after PD and remains alive 22 months later without recurrence. Two patients are disease-free at 38 and 92 months of follow-up. PD for second primary periampullary cancer after resection of extrahepatic bile duct cancer appears feasible and potentially effective. Although no perioperative mortality occurred, major complications were observed. Larger studies are needed to confirm these preliminary findings.

Введение. В настоящее время роль регионарной химиотерапии (РХТ) и лучевой терапии (ЛТ) у больных раком поджелудочной железы окончательно не определена. Цель. Изучить ближайшие и отдаленные результаты комбинации РХТ и ЛТ по сравнению с выполнением панкреатодуоденальной резекции (ПДР) у больных РПЖ, имеющих высокий хирургический риск осложнений и летальности. Материалы и методы. Группу исследования составили 33 больных аденокарциномой головки поджелудочной железы со стадией Т2-3N0-1М0 IB-IIВ и III классом физического статуса по классификации ASA. На первом этапе была проведена РХТ в виде химиоэмболизации (ХЭ) головки поджелудочной железы с гемцитабином и липиодолом с последующей артериальной химиоинфузией гемцтабина и оксалиплатина (схема GEMOX). На втором этапе лечения выполнена ЛТ в режиме дневного дробления дозы (4 Гр в сут.) до суммарной очаговой дозы 50 Гр. В контрольную группу включены 36 больных с аналогичными стадиями заболевания и III классом ASA, которым выполнили ПДР в многопрофильной клинике. Результаты. Госпитальной летальности после химиолучевой терапии не было. Послеоперационная летальность отмечена в группе контроля у пяти (13,9 %) больных. Осложнения III-IV степени по классификации Clavien — Dindo были отмечены только после операции (n = 15, 41,7 %) (р &lt; 0,05). Медиана времени до прогрессирования после химиолучевого лечения составила 7,8 (ДИ: 6,9–8,4) мес., после операции — 10,7 (95 % ДИ: 7,9-15,5) мес. (p &lt; 0,05). Медианы общей и однолетней выживаемости составляли 12,4 (95 % ДИ: 10,5-17,8) мес. и 50 % против 17,4 (95 % ДИ: 11,6-25,5) мес. и 64 % соответственно (p &lt; 0,05). В то же время общая выживаемость, оцениваемая по умершим больным (n = 26 vs n = 28), в обеих группах не различалась: 14,1 (95 % ДИ: 11,5-16,6) мес. и 14,5 (95 % ДИ: 10,5-18,5) мес. (p &lt; 0,05). Выводы. Несмотря на высокую летальность и большое число осложнений, хирургическая операция обеспечивает лучшие показатели выживаемости даже у ослабленных больных. Актуальной является задача выявления неблагоприятных факторов для выполнения ПДР: у таких пациентов безопасной и относительно эффективной альтернативой может быть комбинация РХТ и ЛТ в режиме дневного дробления дозы.

Objective: This study reports the initial series of patients who underwent single-port robotic-assisted pancreatoduodenectomy (SPRPD) using the da Vinci SP system (Intuitive Surgical, Inc., Sunnyvale, CA), demonstrating its technical feasibility and short-term perioperative outcomes. We also aimed to provide a standardized step-by-step SPRPD procedure to facilitate the learning curve.Methods: We analyzed clinical data, surgical steps, and postoperative recovery of patients who underwent SPRPD between August 2024 and December 2024. Short-term outcomes were assessed.Results: Seven patients underwent SPRPD using the da Vinci SP system. Fourteen operative steps were summarized as key elements of the SPRPD procedure. The average age was 68 years, with five males and two females. Diagnoses included pancreatic head adenocarcinoma (three cases), duodenal adenocarcinoma (two cases), common bile duct adenocarcinoma (one case), and intraductal papillary mucinous neoplasm (IPMN, low grade) (one case). The average single-arm docking time was 3.5 minutes. The mean operative time was 584 minutes (9.7 hours), with an estimated blood loss of 143 ml; only one patient required a blood transfusion. No patient required conversion to laparoscopic or open surgery. Regarding short-term oncological outcomes, the largest tumor measured 2.7 cm, and the average number of harvested lymph nodes was 12. A clear resection margin (R0) was achieved in six patients (85.7%), whereas one patient with pancreatic head cancer had a positive superior mesenteric vein margin (14.3%). Delicate surgical anatomical dissection and all types of pancreato-biliary-enteral reconstruction were successfully performed. Postoperative complications included clinically relevant postoperative pancreatic fistula (CR-POPF, grade B) in one patient (14.3%) and delayed gastric emptying in two patients (28.6%). Major complications (Clavien-Dindo grade ≥ III) occurred in four patients (57.1%). There was no 30- or 90-day mortality. Patients resumed oral intake after a mean of 9.2 days, with an average postoperative hospital stay of 22.2 days. Two patients (28.6%) were readmitted because of delayed gastric emptying and vomiting.Conclusions: SPRPD is technically feasible with favorable short-term outcomes. This approach facilitates precise anatomical dissection with negative margins and allows the execution of all types of anastomoses. However, the adoption of SPRPD as a standard approach remains controversial. Long-term outcomes and randomized controlled trials are necessary to define the role of SPRPD more clearly. Standardized operative techniques may shorten the learning curve.

Abstract Endoscopic ultrasound‐guided hepaticogastrostomy (EUS‐HGS) is a useful alternative treatment for endoscopic retrograde cholangiopancreatography (ERCP) failure. However, serious complications sometimes occur. Bleeding is an early complication that occurs during puncture; however, there have been some reports of late‐onset rupture of a pseudoaneurysm. These reports describe cases of patients who underwent metal stent placement. Herein, we report the first case of pseudoaneurysm formation after plastic stent placement via EUS‐HGS. The patient was a 75‐year‐old man with obstructive jaundice due to pancreatic head cancer. ERCP was unsuccessful, and EUS‐HGS was performed with plastic stent placement from B3. The patient subsequently experienced repeated HGS stent failure within a short period, and the plastic stent was replaced each time. No metal stents were placed during treatment. 106 days after EUS‐HGS, the patient presented with hematochezia and shock, and contrast‐enhanced computed tomography suggested the rupture of a pseudoaneurysm in the left hepatic artery branch. Emergency angiography revealed that the pseudoaneurysm originated from the A2+3 branch of the left hepatic artery, and embolization was performed. Subsequently, there has been no recurrence of bleeding, and the patient was eligible for chemotherapy to treat pancreatic cancer.

Background and Objectives: This study aimed to evaluate and compare the early postoperative outcomes of patients who underwent pancreaticoduodenectomy (PD) with total mesopancreatic excision (TMpE) versus conventional pancreaticoduodenectomy (Co-PD) for pancreatic head ductal adenocarcinoma (PDAC). Materials and Methods: Patients who underwent PD for pancreatic head cancer between January 2021 and December 2024 in our clinic and had a pathological diagnosis of PDAC were included. Patients were stratified into two groups according to the surgical technique performed (TMpE-PD vs. Co-PD). Demographic characteristics and early postoperative clinicopathological data were compared between the groups. Results: A total of 41 patients were included: 17 (41.5%) underwent TMpE-PD and 24 (58.5%) underwent Co-PD. Demographic and clinicopathological parameters were comparable between the groups. Although not statistically significant, the TMpE-PD group demonstrated higher R0 resection rates (58.8% vs. 45.8%; p = 0.412) and greater lymph node yield (33.9 vs. 29.1; p = 0.757) compared to the Co-PD group. Overall postoperative complications were more frequent in the TMpE-PD group (82.4% vs. 63.4%; p = 0.034). A smaller pancreatic duct diameter was associated with an increased risk of postoperative complications in both groups, approaching statistical significance (p = 0.053). Multivariable logistic regression analysis revealed that the surgical technique was not an independent risk factor for postoperative complications (OR: 0.64; 95% CI: 0.14–2.83; p = 0.56). No direct correlation was found between resection margin status (R0 vs. R1) and the development of postoperative complications. Conclusions: TMpE demonstrated non-significant trends toward higher R0 resection rates and greater lymph node yield compared with conventional PD. These findings suggest possible oncological benefits without significantly increasing perioperative morbidity.

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.

Pancreaticoduodenectomy remains the only curative intervention for periampullary and pancreatic head cancers, with R0 resection being essential for long-term survival. Nonetheless, the predictive value of preoperative imaging, particularly following neoadjuvant therapy, often remains inadequate. Committing to irreversible surgical steps too early can lead to futile procedures associated with significant morbidity. Here, we introduce the innovative “Total Non-Division Technique,” which strategically combines the superior mesenteric artery (SMA)-first approach and total mesopancreas excision (TMpE) to ensure resectability prior to performing any irreversible maneuvers. The procedure initiates with the Cattell Braasch Valdoni manoeuvre, Kocherisation and division of the ligament of Treitz which facilitates a 270-degree duodenal-jejunal derotation, clarifying the SMA and SMV anatomical relationship. Employing a combined posterior and right medial SMA-first approach allows for early vascular control while safeguarding aberrant hepatic arteries. TMpE (type 2 or 3) is achieved en bloc, providing radical clearance within pl-Ph-II between the SMA and celiac axis. Irreversible surgical actions are intentionally deferred until R0 resectability is established, supporting intraoperative decision-making and allowing for procedure abandonment should oncological criteria not be fulfilled. This surgical method enhances rates of R0 resection and reduces morbidity linked to non-curative operations. By avoiding early bile duct transection, contamination risk is minimized, and delayed pancreatic division optimizes margin status and haemostasis. This innovative approach is safe and follows established principles of oncologic surgery, while introducing an intraoperative “path of escape,” analogous to Sun Tzu’s doctrine of strategic flexibility, ensuring that irreversible commitments are undertaken only upon clear oncological justification.

ABSTRACTBackgroundChyle leak (CL) is a relevant complication of pancreatic surgery, but its incidence, risk factors, clinical and oncologic impacts, and nutritional relevance remain inconsistent and limited.MethodsWe retrospectively reviewed patients who underwent pancreaticoduodenectomy for pancreatic head cancer from 2007 to 2023 at a single institution. The clinical impact of CL was evaluated by prolonged hospital stays and immune‐nutritional status, assessed using the Controlling Nutritional Status (CONUT) score at discharge. Oncologic impact included the administration of adjuvant chemotherapy, the surgery‐to‐chemotherapy interval, overall survival (OS), and recurrence‐free survival (RFS). Predictors of CL were identified through multivariate analyses.ResultsCL occurred in 70 patients (13.8%) and was significantly associated with prolonged hospital stay (OR: 1.947, p = 0.045) and poor CONUT score at discharge (> 6; OR: 1.820, p = 0.036). CL did not significantly impact oncologic outcomes, including adjuvant chemotherapy (p = 0.732), surgery‐to‐chemotherapy interval (p = 0.235), 5‐year OS (p = 0.978), or 5‐year RFS (p = 0.919). Independent predictors of CL included hypertension, lymph node metastasis, delayed gastric emptying, minimally invasive surgery (MIS), and operative time.ConclusionsCL is associated with prolonged hospital stay and poor nutritional status at discharge, but shows no significant impact on long‐term oncologic outcomes.

Red Dichromatic Imaging (RDI) is an advanced endoscopic technology designed to enhance the visualization of gastrointestinal bleeding. While RDI with Mode 2 has demonstrated significant efficacy in the detection and management of esophageal varices, its role in treating anastomotic varices remains underexplored. We report a challenging case of anastomotic variceal rupture, highlighting the advantages of RDI in precise localization and treatment. A woman in her 70s with a history of pancreaticoduodenectomy for pancreatic head cancer and liver metastasis, presented with melena, fever, and suspected cholangitis during chemotherapy. Laboratory findings revealed anemia, leukocytosis, and elevated biliary enzymes. Blood transfusion and antibiotic therapy were initiated. CT revealed portal vein stenosis and contrast extravasation into the jejunum. Endoscopy showed a white plug at the gastrojejunal anastomosis, but no visible varices on white light imaging. RDI with Mode 2 identified subtle color changes, enabling successful N-butyl-2-cyanoacrylate injection. Accumulation of lipiodol confirmed variceal obliteration. No further bleeding occurred, and the patient was discharged in stable condition on hospital day 19. This case suggests that RDI may improve the detection and therapeutic precision of ectopic varices and serve as a valuable adjunct in their management.

Malignant gastric outlet obstruction (MGOO) is a serious complication arising from advanced gastric or pancreatic head cancer, significantly impairing patients’ quality of life by disrupting oral intake and inducing severe gastrointestinal symptoms. With benign causes such as peptic ulcer disease on the decline, malignancies now account for 50–80% of gastric outlet obstruction (GOO) cases globally. This review outlines the pathophysiology, evolving epidemiology, and treatment modalities for MGOO. Therapeutic approaches include conservative management, endoscopic stenting, surgical gastrojejunostomy (GJ), stomach partitioning gastrojejunostomy (SPGJ), and endoscopic ultrasound-guided gastroenterostomy (EUS-GE). While endoscopic stenting offers rapid symptom relief with minimal invasiveness, it has higher rates of re-obstruction. Surgical options like GJ and SPGJ provide more durable palliation, especially for patients with longer expected survival. SPGJ, a modified surgical technique, demonstrates reduced incidence of delayed gastric emptying and may improve postoperative oral intake and survival compared to conventional GJ. EUS-GE represents a promising, minimally invasive alternative that combines surgical durability with endoscopic efficiency, although long-term data remain limited. Treatment selection should consider patient performance status, tumor characteristics, prognosis, and institutional resources. This comprehensive review underscores the need for individualized, multidisciplinary decision-making to optimize symptom relief, nutritional status, and overall outcomes in patients with MGOO.

Purpose: The introduction of Enhanced Recovery After Surgery (ERAS) protocols for pancreaticoduodenectomy (PD) has been considered challenging due to factors such as preexisting malnutrition, sarcopenia, the complexity of the surgery, and the high incidence of postoperative complications, including postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE). This study aimed to determine whether ERAS could be implemented in PD to achieve shorter postoperative hospital stays.Methods: Our novel approach consists of three components. Preoperatively, we routinely assess patients' muscle strength and nutritional status and initiate exercise and nutritional interventions for those identified with sarcopenia or malnutrition. Intraoperatively, we perform pancreaticojejunostomy using a modified Blumgart’s technique with our stent placement policy and utilize new gastrojejunostomy methods to prevent DGE. Principles of postoperative management are early ambulation, early oral intake, and early drain removal. Since April 2020, we have employed this strategy and retrospectively evaluated its effectiveness. We enrolled 71 consecutive patients who underwent open PD with curative intent. Various surgical outcomes, including postoperative hospital stay, were analyzed.Results: There were 41 men and 30 women, with a median age of 70 years. Preoperative diagnoses included pancreatic head cancer in 31, distal bile duct cancer in 12, and others. Median intraoperative blood loss was 310 mL. Grade B POPF occurred in four patients (6%). No cases of DGE were observed. The median postoperative hospital stay was 8 days (range, 6–26 days).Conclusion: We successfully implemented ERAS protocols in PD and achieved a significantly reduced postoperative hospital stay. We propose that this approach is “real minimally invasive surgery," regardless of the surgical technique used.

A Case of Dissociative Symptoms in a Patient with Advanced Pancreatic Head Cancer Presenting with Visual and Auditory Hallucinations