Identifying Factors Associated With Postdischarge Mortality After Readmission Following Pancreaticoduodenectomy.

Non-ampullary duodenal neoplasms (DNs) are rare, heterogeneous lesions for which the optimal surgical strategy remains debated. While pancreatoduodenectomy (PD) is considered the standard for ampullary or locally advanced tumours, limited resection (LR) of the duodenum offers a pancreas-preserving alternative in appropriately selected cases. This study aimed to describe the indications, surgical techniques, and outcomes of LR for non-ampullary DNs. All consecutive patients undergoing LR, including segmental resection (SR), wedge resection (WR), extra-mucosal excision (EME), endoluminal excision (ELE), for non-ampullary DNs at our institution between August 2010 and May 2025 were retrospectively reviewed. Demographic, operative, pathological, and follow-up data were collected from a prospectively maintained database. Disease-specific survival (DSS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method, with subgroup analyses for duodenal adenocarcinoma (DA), gastrointestinal stromal tumors (GIST), and neuroendocrine tumors (NET). Thirty-three patients underwent LR: SR D1 (n = 2, 6.1%), SR D3-D4 (n = 13, 39.4%), WR (n = 13, 39.4%), EME (n = 2, 6.1%), and ELE (n = 3, 9.1%). Median operative time was 219min (IQR 162-278) and median blood loss was 100mL (IQR 50-100). Overall morbidity occurred in 45.4% of patients, with severe complications in 18.2% and no 90-day mortality. Final histology included GIST/leiomyoma (45.4%), DA (18.2%), NET (18.2%), and adenoma (18.2%). At a median follow-up of 66.8months for DA, 75.6months for GIST, and 61.4months for NET, 5-year DSS/DFS rates were 80%/66.7% for DA, with only one recurrence in the GIST group and two recurrences in the NET group (one disease-related death). LR of the duodenum is a safe and effective alternative to PD for selected non-ampullary DNs, with low morbidity, no perioperative mortality, and excellent long-term oncological outcomes in appropriately chosen patients. When technically feasible and without ampullary or pancreatic invasion, LR should be considered the preferred approach for localized duodenal GIST, selected D3-D4 DA, and non-ampullary NET requiring surgery.

Early portomesenteric thrombosis (ePMT) can occur following pancreaticoduodenectomy (PD) and is associated with significant postoperative morbidity and mortality. The aim of this study was to identify risk factors associated with early ePMT following PD. We retrospectively analyzed data from a prospective database including all consecutive patients who underwent PD for benign or malignant tumors at our tertiary center between January 2007 and December 2019. Univariable and multivariable analysis were conducted, between the independent groups using penalized maximum likelihood logistic regression. 374 patients were included. Nine patients developed early ePMT. Postoperative ePMT occurred at a median of 3.5 days [0-40] after surgery. Ninety-day postoperative mortality was significantly higher in the ePMT+ group (OR = 7.1; p < 0.01). Intraoperative blood loss and body mass index (BMI) were independently associated with ePMT following PD (OR = 6.61; IC95 = [1.68;26] and OR = 4.44; IC95 = [1.09;17], respectively). Venous resection during PD and occurrence of POPF were both associated with an increased risk of ePMT, but theses associations were not statistically significant. ePMT following PD is rare but represents a severe postoperative complication associated with high mortality rate. It occurs more often in patients with increased intraoperative blood loss and higher BMI, reflecting greater intraoperative technical difficulty during surgery.

Completion total pancreatectomy is the traditional approach for metachronous pancreatic cancer developing after pancreaticoduodenectomy (PD). However, this method causes significant morbidity and leads to pancreatogenic diabetes. While preserving the pancreatic remnant can maintain its function, it is technically demanding due to postoperative adhesions and altered anatomy. This video demonstrates a standardized laparoscopic approach for remnant-sparing distal pancreatectomy utilizing fluorescence guidance to ensure remnant perfusion. A 69-year-old female, 2.5years post-laparoscopic PD for ampullary cancer, presented with rising CA 19-9 levels and a new well-differentiated adenocarcinoma in the pancreatic tail confirmed by EUS-FNA. We planned a laparoscopic distal pancreatectomy with splenectomy, preserving the prior pancreaticojejunostomy. The 5-port procedure employed a medial-to-lateral approach, dissecting along embryologic fascial planes (Toldt's fascia) to maintain oncologic principles.1 Crucially, Indocyanine green fluorescence imaging was used intraoperatively to confirm adequate perfusion of the preserved pancreatic remnant.2 Standard en bloc lymphadenectomy was performed. The procedure lasted 123min, with estimated blood loss of 20mL. Postoperative recovery was uneventful; drain fluid amylase was normal (23 U/L) on postoperative Day 5, allowing for discharge. Final pathology confirmed a 3.7cm pT2N0M0 (Stage IB) ductal adenocarcinoma with negative margins. At 6-month follow-up, the patient showed no recurrence and maintained stable endocrine and exocrine function. Laparoscopic remnant-sparing distal pancreatectomy is a feasible and safe oncologic approach for selected patients with metachronous cancer following PD. The combination of embryologic plane dissection and fluorescence imaging facilitates this complex reoperation, allowing for preservation of essential endocrine function without compromising oncologic principles.

A 56-year-old man presented with hyperglycemia and weight loss. Imaging revealed a pancreatic head mass with features suggestive of primary pancreatic carcinoma. 18F-FDG PET/CT confirmed a hypermetabolic lesion without evidence of distant metastasis. Following the Whipple procedure, histopathology and immunohistochemistry (CD34+, Vimentin+), together with a history of resected ankle sarcoma, established the diagnosis of a solitary pancreatic metastasis from dermatofibrosarcoma protuberans (DFSP). This case highlights the diagnostic difficulty posed by solitary pancreatic metastases, which can closely mimic primary pancreatic cancer. A comprehensive approach integrating clinical history, tumor markers, and multimodality imaging is essential for accurate differentiation.

Postoperative pancreatic fistula (POPF) remains a major cause of morbidity after pancreatoduodenectomy (PD), with an incidence of more than 30% in patients with small pancreatic ducts. Evidence supporting preventive measures remains limited. Biodegradable stent placement across the pancreaticojejunostomy (PJ) may reduce the POPF. This study represents the first randomised controlled trial evaluating biodegradable stents in patients with high-risk pancreaticojejunostomies. This single centre, patient- and assessor-blinded, randomised clinical trial included patients undergoing PD with a main pancreatic duct < 5mm. Patients were randomised 1:1 to receive a fast-degrading (12-day) ARCHIMEDES biodegradable stent or no stent. The primary endpoint was Clinically relevant postoperative pancreatic fistula CR-POPF. Secondary outcomes included biliary leakage, major complications (Clavien-Dindo ≥ III), length of stay, readmission, and mortality. In this interim analysis, 50 patients were randomised (26 received a stent, 24 no-stent). Baseline characteristics including Fistula Risk Score (FRS) were comparable. Patients were mainly operated for malignancies. CR-POPF incidence was lower in stent-group compared to no-stent group. However, this difference was not significant (11,50% vs. 25%, p = 0,20). Biliary leakage and intraoperative blood loss were similar between groups. Two cases of mild, self-limiting postoperative pancreatitis occurred in the stent group. No 30- or 90-day mortality was observed. Median length of stay and readmission rates did not differ significantly. Interim results from the first blinded, randomised trial with a biodegradable stent, showed no significant reduction in CR-POPF, but a trend towards reducing them. Completing the inclusion and initiating larger multicentre trials are needed to clarify its clinical benefit.

Postoperative pancreatic fistula (POPF) is a serious complication following pancreaticoduodenectomy (PD). While numerous studies have investigated POPF incidence and risk factors, few have focused on POPF healing time (POPF-HT). Skeletal muscle mass has been increasingly recognized as an endocrine organ involved in interorgan communication. The aim of this study was to evaluate how skeletal muscle mass influenced the healing time of POPF after PD. This investigation included patients who developed POPF of grade B-C after PD with pancreaticojejunostomy during the study period. POPF-HT was defined as the duration from the date of PD to the removal of all drains placed for POPF treatment. Skeletal muscle mass was assessed based on preoperative computed tomography images. Clinical factors associated with POPF-HT were analyzed, including skeletal muscle index (SMI). The mean POPF-HT was 40 ± 15 days (median: 37 days; range: 21-105 days). Compared to those with high SMI, patients with low SMI had a significantly longer POPF-HT (46 ± 18 days vs. 37 ± 11 days, p = 0.0101). In univariate analysis, low SMI was significantly associated with prolonged POPF-HT (hazard ratio: 0.5655, 95% confidence interval: 0.3687-0.8673, p = 0.0090). Kaplan-Meier curves confirmed that patients with low SMI exhibited significantly delayed cumulative POPF healing (p = 0.0065). Decreased skeletal muscle mass is significantly associated with prolonged POPF-HT after PD. Therefore, preoperative SMI may serve as a potentially modifiable factor associated with POPF-HT.

The serum albumin to creatinine ratio (sACR) has emerged as a potential biomarker for predicting postoperative outcomes, yet its relationship with length of stay (LOS) in patients undergoing pylorus-preserving pancreaticoduodenectomy (PPPD) remains underexplored. This study aimed to investigate the nonlinear correlation between sACR and LOS in this patient population. A secondary analysis was conducted on retrospective data from 809 patients who underwent PPPD. LOS was dichotomized into short (≤ 41 days) and long (> 41 days) based on the median value. sACR was calculated as the ratio of serum albumin (g/L) to serum creatinine (μmol/L). Demographic, clinical, laboratory, and perioperative variables were analyzed. Threshold effect analysis was performed using a 2-piecewise linear regression model to identify potential inflection points in the sACR-LOS relationship. Multivariate adjustments were made for demographic, clinical, and laboratory variables to control for confounding factors. A significant nonlinear relationship between sACR and LOS was identified, with an inflection point at 33.64. In patients with sACR levels below 33.64, each unit increase in sACR was associated with a 13% reduction in the odds of prolonged LOS (odds ratio = 0.87, 95% CI: 0.76-0.99, P = .038). No significant association was observed above this threshold (odds ratio = 1.03, 95% confidence interval: 0.99-1.08, P = .118). This study demonstrates a critical threshold effect of sACR on LOS in PPPD patients, highlighting its potential as a predictive biomarker for postoperative recovery. Optimizing sACR levels, particularly in patients with values below 33.64, may reduce the risk of prolonged hospitalization.

Various analgesic techniques have been employed for pain management in pancreatoduodenectomy (PD). However, the optimal technique remains unclear. This network meta-analysis seeks to appraise the efficacy and adverse effects of different analgesic techniques. Cochrane, Embase, Web of Science, and PubMed databases were searched up to January 10, 2025. Clinical studies on pain control following PD were included. Primary search terms included PD and pain. Two reviewers separately screened studies, extracted data, and evaluated the risk of bias. A third reviewer resolved their dissents. The risk of bias was assessed via the NIH quality assessment tool. Data analysis was carried out via R version 4.4.1. The primary outcome was postoperative opioid consumption, and the secondary outcomes included pain scores at 24 and 48h after surgery and postoperative nausea and vomiting (PONV). Effect sizes were presented as standardized mean differences (SMD), mean differences (MD), and relative risk (RR). A total of 10 studies were included, including five randomized controlled trials and five cohort studies, involving a total of 975 patients. The network meta-analysis revealed that compared to epidural block with other analgesia, parecoxib-IV was most effective in reducing opioid consumption after surgery (SMD: -3.7, 95% CI: [-4.3, -4.1]). Additionally, wound infiltration (WI), transversus abdominis plane (TAP) block, electrical muscle stimulation, and intrathecal morphine (ITM)+TAP can substantially reduce opioid consumption after surgery. For pain scores, parecoxib-IV was most effective in controlling postoperative pain at rest (MD: -0.32, 95% CI: [-4.9, -0.15]). Regarding PONV, WI (RR: 0.70, 95% CI: [0.51, 0.94]) and acetaminophen-IV (RR: 0.35, 95% CI: [0.099, 0.94]) were linked to fewer adverse events. Compared with epidural block, intravenous parecoxib was ranked as the most effective intervention for reducing postoperative opioid consumption. WI, TAP block, electrical muscle stimulation, and ITM+TAP also demonstrated superior effects in reducing opioid consumption relative to epidural analgesia. Regarding secondary outcomes, intravenous parecoxib was the most effective in reducing postoperative pain scores at rest, while both WI and intravenous acetaminophen were associated with a lower incidence of PONV. These findings suggest that alternative analgesic strategies, particularly intravenous parecoxib, may offer advantages over epidural block. Given the limited number of studies currently included, these conclusions need to be further validated by future high-quality research. PROSPERO registration: https://www.crd.york.ac.uk/prospero/ (CRD: 420251030763).

Routine use of surgical drains after abdominal operations has largely been abandoned over the past decades. Studies have failed to demonstrate benefits of routine drainage following liver, gallbladder, gastric, and colorectal surgeries. Until recently, intraoperative placement of abdominal drains was the gold standard in pancreatoduodenectomies (PDs) due to concerns about uncontrolled postoperative pancreatic fistula (POPF). A large randomized trial in 2014 reported increased mortality in patients without postoperative drain placement. However, as the study did not stratify participants based on their preoperative risk of developing a POPF, further research is needed. Limited evidence from a non-randomized cohort suggests that omitting drains may be safe in very low-risk settings. However, a larger comparative study, including a broader range of PD cases, is necessary to confirm these findings. This is a two-arm, randomized, controlled, non-blinded, multicenter trial comparing intra-abdominal drain placement with no drain placement during planned pancreatoduodenectomies (PDs). Eligible patients who meet the inclusion criteria will be assessed for their individual risk of postoperative pancreatic fistula (POPF) using a risk scoring system. They will then be randomized into either the drain placement or no drain placement group. The groups will be compared using the chi-square test for categorical variables and Fisher's exact test. Logistic regression models will be used to calculate odds ratios for morbidity. Univariable and multivariable models will assess the impact of drain placement on clinical outcomes. This trial aims to determine whether omitting routine intraoperative drain placement reduces the risk of complications in patients undergoing pancreatoduodenectomy (PD). It will provide level 1 evidence on the association between routine intra-abdominal drainage and postoperative complications in patients with a low to intermediate risk of developing a postoperative pancreatic fistula (POPF). The findings will contribute to future treatment guidelines by expanding the available knowledge on optimal drainage strategies. ClinicalTrials.gov Identifier: NCT05270564. Registered on February 16 2022.

In 2018, Inoue et al.1 introduced a systematic classification of the extent of dissection along the celiac axis (CA) and hepatic artery (HA) during open pancreaticoduodenectomy (PD). Three levels of perivascular dissection were defined according to surgical indication: level 1, limited organ resection without oncological dissection for benign or low-grade malignant lesions; level 2, formal lymphadenectomy with preservation of the perivascular nerve plexus for borderline or low-grade malignancies; and level 3, radical dissection, including perineural clearance for pancreatic cancer. As robotic PD is increasingly adopted, it should reproduce the same oncological standards established in open surgery.2-4 However, a standardized robotic technique capable of achieving all levels of the Inoue classification has not yet been clearly described. This video article aims to present a stepwise robotic approach to CA-HA dissection consistent with these principles. We present a comprehensive surgical video demonstrating a standardized robotic technique to achieve graded dissection of the CA and HA from level 1 to level 3. A supplementary video specifically illustrates advanced CA-HA dissection in the setting of vascular involvement requiring resection and reconstruction. Independently of the dissection level, three constant technical principles are systematically applied: (1) arterial control through vessel loop encirclement of the HA to avoid undue manipulation; (2) a selective and stepwise use of robotic instruments according to the depth of dissection, with monopolar curved scissors used to develop the superficial planes and Maryland bipolar forceps employed for precise periadventitial skeletonization of the arterial structures, thereby minimizing mechanical and thermal injury to the arterial wall. Energy sealing devices such as the vessel sealer (Intuitive Surgical, Sunnyvale, CA, USA) are used selectively and only away from major arteries, mainly for lymphatic or venous division and for final hemostasis once lymph nodes have been mobilized from the arterial wall. Alternatively, cold dissection with scissors can be used for precise arterial divestment, as previously described by Kauffman et al.5; (3) a structured four-hand robotic strategy involving two experienced hepato-pancreato-biliary surgeons to optimize exposure and vascular safety, with one surgeon operating at the console and a second surgeon assisting at the bedside to provide dynamic retraction, suction, and vascular control. All three levels of CA-HA dissection according to the Inoue classification were successfully achieved robotically. The robotic platform enabled stable magnified visualization and precise skeletonization along vascular and perineural planes. Advanced dissections, including circumferential perineural clearance, were feasible without intraoperative arterial injury or uncontrolled vascular complications, even during level 3 dissections or when vascular resection and reconstruction were required. A graded clearance of the CA and HA according to the Inoue classification can be safely reproduced during robotic PD, supporting standardization of oncological principles across different levels of perivascular dissection.

Safety and efficacy of Enhanced Recovery after Surgery (ERAS) in pancreaticoduodenectomy combined with vascular reconstruction.

Background Pancreaticoduodenectomy (PD) is associated with high postoperative morbidity, particularly infectious complications. In patients undergoing preoperative biliary drainage (PBD), bile contamination is common and may lead to a mismatch between standard cephalosporin-based prophylaxis and biliary pathogens. Methods We conducted a retrospective single-center cohort study including 65 patients undergoing PD between December 2021 and May 2025. Of these, 42/65 (64.6%) underwent PBD. Patients received perioperative antibiotic prophylaxis with cefazolin or piperacillin/tazobactam plus fluconazole, according to institutional protocols. Intraoperative bile cultures were obtained in 44/65 patients, yielding 39 positive cultures with multiple isolates. Infectious complications and major morbidity (Clavien-Dindo > IIIA) were assessed. Multivariable logistic regression was performed to identify predictors of infectious complications, with subgroup analysis in drained patients. Results Positive bile cultures were observed in 38/42 (90.5%) drained patients compared with 1/23 (4.3%) non-drained patients (p<0.001). A total of 39 positive bile cultures yielded multiple isolates, including Enterococcus spp. in 24/39 (61.5%) cultures and Candida spp. in 10/39 (25.6%) cultures. Cefazolin did not provide coverage for at least one isolate in 30/39 (76.9%) cultures, compared with 13/39 (33.3%) for piperacillin/tazobactam plus fluconazole. In multivariable analysis restricted to drained patients, piperacillin/tazobactam plus fluconazole was independently associated with fewer infectious complications (odds ratio (OR): 0.13; 95% confidence interval (CI): 0.02-0.92; p=0.041). Conclusions In patients undergoing PD after PBD, bile contamination is frequent and characterized by enteric organisms and a relevant fungal component. Under these conditions, cefazolin prophylaxis shows a high rate of expected non-coverage, whereas piperacillin/tazobactam plus fluconazole provides broader microbiological coverage and is associated with reduced infectious complications. These findings support a tailored prophylactic strategy based on biliary colonization in PBD patients.

A decade of pancreatoduodenectomy outcomes for pancreatic adenocarcinoma: 2014-2023 analysis of the N SQIP pancreatectomy PUF database: A decade of pancreatoduodenectomy in NSQIP.

Surgery and the perioperative management for periampullary carcinomas are translated from the more frequent ductal adenocarcinoma of the pancreatic head (hPDAC). After implementation of the pathological circumferential resection margin (CRM), true margin negativity dropped dramatically for hPDAC patients. The frequent infiltration of the mesopancreas (MP) is a causative factor for incomplete resection. It remains unknown if the oncological relevance of the MP remains exclusive for the hPDAC or if it can be translated into the operative management for periampullary carcinomas as well. Patients who received oncological pancreatoduodenectomies (PD) for dCCAs and ACs from 2015 to 2025 at our department were included in this study (n =100). The MP status was retrieved from the histopathological reporting. MP infiltration was evident in 36.4% and 62.2% of the AC and dCCA patients respectively (p = 0.015). Across both tumour entities, mesopancreatic involvement emerged as a marker of significantly worse overall survival (AC: p = 0.002; dCCA: p = 0.013). Distal cholangiocarcinomas presented with a frequent infiltration into the mesopancreas. A positive infiltration status of the MP significantly correlated with incomplete resection status in ampullary carcinoma. In addition, MP infiltration proved to be an adverse prognostic factor for overall survival in periampullary carcinoma patients, underscoring its potential role in perioperative staging and its possible relevance for surgical decision-making. This is the first study revealing insights into the infiltrative prevalence of the MP in periampullary carcinomas. Mesopancreatic involvement may not be exclusive to pancreatic cancer and warrants further investigation in other periampullary malignancies.

Up to 40% of patients undergoing pancreatoduodenectomy (PD) for resectable pancreatic ductal adenocarcinoma do not receive adjuvant chemotherapy (aCT). This study aimed to evaluate the impact of postoperative pancreatic fistula (POPF) on aCT delivery and timing and to explore how preoperative variables influence these outcomes according to the occurrence of a POPF. This multicenter retrospective study included patients from 25 pancreatic centers. Propensity score matching was performed based on anatomical, biological, and conditional variables. Multivariable regression analyses were used to identify independent predictors of aCT omission and delay. Among 1590 patients, 267 (16.8%) developed a POPF. Overall, aCT was administrated in 1,146 patients (72.1%) with a median time to first dose delivery of 56 days (26). After matching, POPF was associated with a significantly lower likelihood of aCT delivery (p < 0.001) and a significant delay in its initiation (p < 0.001). Independent predictors of aCT omission were age ≥70 (odds ratio [OR] 2.480, 95% confidence interval [CI] 1.439-4.274; p < 0.001), chronic renal failure (OR 4.554, 95% CI 1.320-15.708; p = 0.016), and chronic obstructive pulmonary disease (OR 2.775, 95% CI 1.021-7.546; p = 0.045) when POPF occurred. In the absence of POPF, apart from age ≥70, venous contact (OR 1.574, 95% CI 1.114-2.224; p = 0.010) and tumor size > 20 mm (OR 0.713, 95% CI 0.523-0.972; p = 0.032) were predictors of aCT delivery. Postoperative pancreatic fistula is a key driver of aCT delivery after pancreatoduodenectomy. Its interaction with patient frailty highlights the need for preoperative risk assessment to better select candidates for upfront surgery in resectable pancreatic ductal adenocarcinoma.

Pancreaticoduodenectomy (PD) is the standard treatment for periampullary tumors, but it is technically challenging. Evidence directly comparing open, laparoscopic, robotic, and hybrid approaches is limited. This study conducts a network meta-analysis (NMA) to compare the perioperative and oncologic outcomes of open PD (OPD), laparoscopic PD (LPD), robotic PD (RPD), and hybrid PD. We searched PubMed, EMBASE, and the Cochrane Library for studies published between January 1994 and August 2024. We included randomized controlled trials and comparative observational studies that evaluated at least two PD approaches. Perioperative outcomes were the primary endpoints, while oncologic safety served as a secondary endpoint. A random-effects NMA was performed, establishing treatment hierarchies through ranking probabilities (PROSPERO ID: CRD420250365864). A total of 78 studies were included (5 randomized and 73 retrospective). RPD was associated with lower blood loss compared to OPD (mean difference [MD], -163.85 mL) and LPD (MD, -84.14 mL). Hospital stays were also shorter for RPD compared to OPD (MD, -2.50 days) and LPD (MD, -1.88 days). In contrast, OPD was the most time-efficient approach compared to LPD (MD, -77.61 minutes) and RPD (MD, -73.30 minutes). Mortality rates, severe complications, clinically relevant postoperative pancreatic fistula rates, and reoperation rates were comparable across all surgical approaches. In terms of oncologic safety, lymph node yield and R0 resection rates were similar for all modalities. While OPD is the most time-efficient approach, RPD provides significant advantages in reducing intraoperative blood loss and shortening hospital stays compared to both LPD and OPD.

Preoperative biliary drainage (PBD) is commonly used prior to pancreatoduodenectomy (PD), but its histologic effects on the extrahepatic bile duct are not well understood in humans. This study aimed to prospectively measure pericholedochal fibrosis (PCF) in PD specimens after plastic biliary stenting to assess its extent and clinical significance. Consecutive patients undergoing PD were divided into two groups: those who received PBD (n = 22) and non-drained controls (n = 24). Patients who had neoadjuvant chemotherapy were excluded to focus on stent-related effects. Common bile duct (CBD) specimens were analyzed using standardized Masson's trichrome staining. Digital morphometry quantified CBD dimensions, collagen area, and collagen density. Histologic markers were correlated with stent dwell time and surgical outcomes. PBD was linked to a substantial increase in PCF. Stented ducts showed significantly greater wall thickness (6,554 vs. 499 μm; p < 0.001), total collagen area (p < 0.001), and collagen density (p < 0.001) compared to controls. Fibrosis developed rapidly, becoming clearly evident by day 6, with no significant correlation between collagen burden and stent dwell time (median 10 days). Despite these pronounced histologic changes, operative time (230 vs. 230 minutes; p = 0.98) and postoperative complication rates did not differ significantly between the groups. Short-term PBD with plastic stents causes rapid, intense, and persistent PCF that stabilizes soon after stent placement. Although this fibrotic response did not negatively impact surgical outcomes at a high-volume center, the findings underscore the significant tissue remodeling triggered by stenting and advocate for the careful use of PBD.

Introduction . Fluid therapy is an integral component of anesthetic and resuscitation management in the early perioperative period following abdominal oncological surgery. Optimizing fluid therapy remains particularly challenging in hepatopancreatobiliary surgery, particularly during pancreaticoduodenectomy (PD). Currently, there is no consensus in the scientific community regarding the optimal regimen and strategy for fluid therapy during PD. The objective was to analyze the clinical efficacy of different infusion therapy strategies in PD. Materials and methods. A review of studies, systematic reviews, meta-analyses, and clinical guidelines on fluid therapy during pancreaticoduodenectomy was conducted. The search was conducted using PubMed, the Cochrane Controlled Clinical Trials Register, Google Scholar, and e-Library (for Russian authors). Studies from the past ten years were primarily reviewed. Inclusion criteria for the review were text publications comparing restrictive, targeted, and liberal perioperative fluid therapy in patients undergoing PD. Exclusion criteria were duplicates, abstracts, abstracts without a full-text version, and publications not related to the study objective. Results . Perioperative fluid therapy is a critical factor significantly affecting PD outcomes. Both excessive (liberal) and overly restrictive fluid regimens are associated with an increased risk of postoperative complications, including those specific to PD. An optimal fluid therapy strategy for PD should be balanced, avoiding both hyperand hypovolemia, and take into account individual patient risk factors (pancreatic duct diameter, pancreatic consistency, albumin level). Conclusion . A modern approach to the strategy of infusion therapy in PD should be personalized, physiologically justified and dynamically controlled and based on a constant assessment of the balance between ensuring adequate organ perfusion and preventing iatrogenic hyperhydration.

Pancreaticoduodenectomy (PD) in dialysis patients is rare but carries a high risk of complications and mortality. This study aimed to identify preoperative factors associated with severe postoperative complications and mortality. Using the Japanese National Clinical Database, 329 dialysis patients undergoing PD between 2016 and 2020 were retrospectively analyzed. Multivariable penalized logistic regression identified preoperative risk factors for Clavien-Dindo classification (CDC) grade ≥ 4 complications, 30-day mortality, operative mortality, postoperative sepsis, and postoperative pancreatic fistula (POPF) (grade B or C). CDC grade ≥ 4 complications, 30-day mortality, and operative mortality occurred in 10.3%, 5.5%, and 11.2%, respectively. Diet- or oral medication-treated diabetes (Odds ratio 5.19, 95% confidence interval 1.19-22.66) and insulin-treated diabetes (7.50, 1.61-34.93) independently predicted 30-day mortality. Serum albumin levels < 3.0 g/dL independently predicted operative mortality (2.72, 1.05-7.02), while cardiovascular disease showed a borderline association (2.15, 0.95-4.85). Elevated CRP was significantly associated with postoperative sepsis (2.47, 1.07-5.67), and pancreatic cancer was associated with a lower risk of POPF (grade B or C) (0.59, 0.37-0.94). Dialysis patients undergoing PD face perioperative risks. Early mortality is driven by acute metabolic and infectious vulnerability, whereas operative mortality reflects diminished physiologic reserve related to malnutrition and cardiovascular comorbidity.