Mount, Jared

Background: Pancreatic resection (Pancreatoduodenectomy, PD, distal pancreatectomy, DP, or total pancreatectomy, TP) is the standard of care for resectable pancreatic adenocarcinoma (PDAC). Despite advances in multimodal therapy, recurrence rates remain high, approaching 80%, and continue to drive poor overall survival. Objective: This review evaluates the burden and clinical significance of localized recurrence in PDAC and critically examines the potential role of intraoperative radiation therapy (IORT) in improving locoregional disease control. Results: Distant recurrence remains the predominant pattern of failure, occurring in 55–75% of patients, most commonly involving the liver, lungs, and peritoneum. However, isolated local recurrence, observed in approximately 17–32% of patients, represents a clinically meaningful subset associated with significant morbidity and potential for subsequent metastatic progression. IORT, delivered as a single high-dose radiation treatment to the tumor bed at the time of surgery, enables precise targeting of areas at highest risk for residual microscopic disease while minimizing radiation exposure to adjacent radiosensitive structures. Retrospective and meta-analytic data, while limited, suggest that IORT is associated with improved local control and modest survival benefit without a significant increase in perioperative morbidity, though interpretation is limited by study heterogeneity and lack of randomized control trials. Conclusion: IORT represents a rational adjunct in the multimodal management of PDAC, particularly for patients at high risk of locoregional failure, including those with borderline resectable or locally advanced disease, nodal involvement, perineural invasion, or concern for margin positivity. Prospective studies are needed to better define optimal patient selection and to clarify the role of IORT in the modern treatment paradigm.

Introduction: An 83-year-old female was discovered to have an incidental circumferential duodenal adenoma by upper endoscopy after being evaluated for irritable bowel syndrome. Imaging revealed a dilated common bile duct and main pancreatic duct but no evidence of malignancy. Therefore, she was considered a candidate for surgical removal. Methods and Materials: Using robotic-assisted surgery, a 4 trocar approach was employed involving three 8-mm and one 12-mm robotic trocar apart. 1 A standard cholecystectomy followed by careful dissection of the duodenum from the pancreas head was performed. The ampulla was identified, and the duodenum was laterally retracted with transection of the identified ampulla with exposure of the pancreaticobiliary orifice. A two-layered duct to mucosa pancreaticobiliary anastomosis was established between the common bile, pancreatic duct, and the jejunum. A side-to-side stapled gastrojejunostomy was constructed and the operation concluded. 2 , 3 Results: Pathological analysis revealed a noninvasive polypoid lesion within the duodenum measuring 7.5 × 5.0 × 0.6 cm. The surgery was completed in 350 minutes with blood loss of 100 mL. There were no postop complications, and the patient was discharged on the fifth day. The patient had some gastric symptoms post discharge which subsided with time. Conclusions: This case highlights the feasibility and safety of robotic resection for an obstructing duodenal polyp in complex anatomical regions, demonstrating its clinical utility and relevance for the management of benign ampullary duodenal lesions. Patient Consent Statement: The patient who was operated upon issued consent for operative data to be used for publication, under Mayo Clinic, Jacksonville, signed consent forms. The author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. Conflict of Interests: This article is not under consideration by any other journal, and all authors have approved the article. None of the authors have any competing financial interests. Runtime of video: 9 minutes and 33 seconds.

Background Pancreatoduodenectomy (PD) is the only curative treatment for pancreatic cancer. Neoadjuvant therapy (NAT) has enhanced survival, especially for downstaging advanced tumors, while also introducing complexities and new complications. Despite surgical advances, some PD attempts remain unsuccessful. The management of these cases is not well defined. This study analyzes outcomes of repeat PD performed by two high-volume surgeons following previously unsuccessful attempts. Methods We retrospectively analyzed patients with pancreatic neoplasm undergoing successful pancreaticoduodenectomy (2013-2024) at two high-volume centers under two experienced surgeons. Only cases with prior aborted PD attempts for non-metastatic disease were included. Data from institutional records provided outcomes on failure reasons, procedure timing, surgical details, and 90-day complications. Results Of the 858 PD cases, 18 patients (2.1%; 12 males, 6 females; median age 69 years) had prior unsuccessful PD attempts at other institutions. Initial tumors were borderline resectable (33.3%), resectable (22.2%), or locally advanced (22.2%). Main causes for initial failure were vascular involvement (41.2%) and tumor infiltration (17.6%). Median time between attempts was 246 days, with 77.8% receiving chemotherapy before the second attempt. The second procedure achieved R0 resection in 94.4% of cases. Major 90-day complications occurred in 23.5% of patients, with no perioperative mortality. Disease recurrence occurred in 38.9% within the first year. Conclusion Repeat PD after an aborted attempt is feasible in select patients at specialized centers. However, complication and recurrence rates emphasize the need for careful patient selection. Further research is needed to optimize management strategies.