Stauffer, John

ABSTRACT Background and Objectives Pancreatic ductal adenocarcinoma (PDAC) remains highly lethal, but the contribution of nonbiological factors to long‐term survival is unclear. We evaluated demographic, socioeconomic, clinical, treatment, and care‐delivery factors associated with 3‐year survival and whether these associations persisted at 5 years. Methods National Cancer Database patients with stage I–III PDAC diagnosed from 2012 to 2022 were analyzed using multivariable logistic regression adjusted for treatment pathway. Results Among 57,053 patients, 51,071 were eligible for a 3‐year analysis, and 12,205 (23.9%) survived. Compared with chemotherapy alone, surgery with chemotherapy (OR, 7.12; 95% CI, 6.64–7.63) and surgery alone (OR, 3.84; 95% CI, 3.49–4.23) had the strongest associations with survival. Younger age, lower comorbidity, Asian race, Spanish/Hispanic ethnicity, private insurance, lower grade, body or tail location, and lower nodal burden were independently associated with survival. Black race and treatment timing were not significant after adjustment. Findings were directionally consistent at 5 years. Conclusion Demographic, socioeconomic, and clinical factors independently influence 3‐year survival in PDAC. These findings underscore the need to complement biologic and therapeutic advances with structural interventions, such as insurance expansion and improved access to high‐quality centers, to mitigate disparities and improve outcomes in this highly lethal cancer.

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.

ABSTRACT Background Readmission is considered as a surgical quality indicator. More data regarding predictors of readmission and outcomes after surgery for colorectal liver metastasis are needed. Using a propensity score match to create a 1:2 match of cases:controls for 90‐day. Readmission, the matching variables used for balance included age, tumor size, estimated blood loss, and type of resection (minor or major). T‐tests were used for continuous measures, Fisher's exact test was used for categorical data, and the Kaplan–Meier method was used to estimate survival. p < 0.05 was considered significant. Methods Retrospectively examined 935 patients with CLM from 2000 to 2018. Using a propensity score match to create a 1:2 match of cases:controls for 90‐day. Readmission, the matching variables used for balance included age, tumor size, estimated blood loss, and type of resection (minor or major). T‐tests were used for continuous measures, Fisher's exact test was used for categorical data, and the Kaplan–Meier method was used to estimate survival. p < 0.05 was considered significant. Results 935 patients were included in the initial sample with 896 eligible for inclusion in the propensity matching. The average age of the population was 59% and 59% male. Overall readmission rate was 8.0%. Median time to readmission was 14 days. In the propensity score matched sample, readmitted patients had higher rates of organ space infection (28% vs 2% and p < 0.0001), bile leak (26% vs 1% and p < 0.0001), and liver failure (9% vs 2% and p = 0.042). There was no difference in LOS (7 days versus six days and p = 0.40), overall survival (median 39.7 vs 41.0 months and p = 0.79), or rate of adjuvant therapy (68% for both and p > 0.99). Conclusion Patients readmitted for intermediate and late complications after surgery for CLM can recover and receive adjuvant therapy with no adverse effect on overall survival. Organ space infection, bile leak, and liver failure are highly associated with readmission.

Background: Upfront resectable pancreatic ductal adenocarcinoma (PDAC) is defined by the NCCN as disease with ≤180° portomesenteric vein (PMV) abutment. However, the clinical significance of PMV abutment in this cohort remains unexplored, and we sought to investigate its impact. Methods: This multi-institutional study included patients who underwent pancreatoduodenectomy (PD) for upfront resectable PDAC from 2002 to 2023. Patients with PDAC with ≤180° PMV abutment were compared with those without. Overall survival (OS) was compared and stratified based on whether patients underwent upfront surgery or neoadjuvant therapy (NAT). Results: Among 1,446 patients included, 521 (36.0%) had PMV abutment. Median OS for patients with PMV abutment was 28.8 months compared with 31.2 months for those without ( P =.17). In a stratified analysis of patients who underwent upfront surgery, patients with PMV abutment had worse OS (19.2 vs 27.6 months; P <.05) and lower R0 resection rates (63.1% vs 87.2%; P <.05) compared with those without. However, in patients who underwent NAT, this difference in R0 resection rate was not observed (91.4% vs 94.0%, respectively; P =.27). Furthermore, there was no significant difference in median OS with NAT (42.5 vs 51.6 months, respectively; P =.48). Conclusions: In this largest cohort to date of patients with upfront resectable PDAC, PMV abutment was associated with worse OS compared with no PMV abutment when an upfront resection strategy was used. The use of NAT in patients with PMV abutment mitigated this survival difference with increased R0 resection rates. These findings suggest that patients with upfront resectable PDAC with PMV abutment benefit from a NAT approach for optimal survival outcomes, and that the current criteria guidelines need to be redefined.

Postoperative pancreatic fistula (POPF) is a critical complication following pancreatic surgeries, marked by leakage of pancreatic fluid due to anastomotic or pancreatic duct failure. Recent advancements have refined its definition, risk classification and management strategies. This review emphasises discussing new definitions, classification updates, predictive factors (both pancreatic and non-pancreatic), comparisons of surgical techniques and therapeutic advancements. Emerging trials and innovations, such as robotic-assisted surgery and personalised stents, are also addressed. The evolving understanding of POPF underscores the need for holistic and patient-centred surgical strategies.

Background: Surgical resection (SR) and liver transplantation (LT) are the main curative options for non-hepatocellular carcinoma (non-HCC) liver malignancies, including colorectal liver metastases (CRLMs), intrahepatic cholangiocarcinoma (iCCA), hilar cholangiocarcinoma (hCCA), and neuroendocrine tumor liver metastases (NETLMs). Resection aims for negative margins and adequate hepatic reserve, while LT offers treatment for unresectable disease but is limited by donor scarcity, immunosuppression, and ethical constraints. Methods: A targeted literature search (2005–2025) was conducted using PubMed and Google Scholar with predefined MeSH terms combining “liver resection,” “hepatectomy,” and “liver transplantation” across non-HCC malignancies. Relevant studies, reviews, and guidelines were included. Results: For CRLMs, SR remains standard with 5-year overall survival (OS) up to 58%, while LT offers 60–83% in highly selected unresectable cases. In iCCA, resection achieves median survival around 40 months, and LT yields OS up to 69% in very early or neoadjuvant-controlled disease. For hCCA, the Mayo protocol combining neoadjuvant therapy with LT provides 5-year OS of 65–80%. In NETLMs, LT achieves 63–97% OS under strict criteria. Conclusions: SR remains first-line for resectable non-HCC malignancies, while LT provides superior outcomes in unresectable yet biologically favorable disease, emphasizing careful selection and organ allocation.

Introduction Due to rising incidence of Hepato-Pancreato-Biliary (HPB) malignancies and more effective therapies, there are increased survivors after curative surgery but little emphasis is placed on survivorship. This study aims to evaluate the value and yield of postoperative surveillance of surgically treated HPB cancer patients within a single surgeon’s practice. Methods A retrospective 1-year (2024) review identified 128 unique patients with prior surgical resection of a HPB malignancy undergoing active cancer surveillance by the surgical team. We excluded patients with benign indications for surgery or active cancer surveillance outside of the surgical team. Results Of these, 112 (87.5%) and 16 (12.5%) underwent pancreatic and hepatobiliary resection, respectively. Median follow up was 1.5 years from the index operation (IQR: 0.7-2.8 years). Pancreatic pathology was pancreatic adenocarcinoma (PDAC), neuroendocrine, or miscellaneous in 70, 25, and 9 patients, respectively. Hepatobiliary pathology was cholangiocarcinoma (CCA), metastatic colorectal cancer, or hepatocellular carcinoma in 16, 6, and 2 patients, respectively. We identified 12 (9.3%) patients who had findings during the study time period resulting in a repeat HPB surgery. In addition, we identified 12 (9.3%) patients who required referral to another department for additional medical, surgical, or interventional treatments. The remaining 104 (81.2%) patients had findings of either no disease recurrence or stable disease with continued surveillance as a recommendation. Conclusion This study underscores the value of cancer surveillance for HPB cancer patients, demonstrating a yield of nearly 20% of patients with findings requiring repeat surgical intervention or referral to other departments.

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 Whistal (Whipple + Distal) is a rare parenchyma-preserving technique for select patients with disease in both the pancreatic head and tail, sparing a disease-free middle segment. It may also be used after prior partial pancreatectomy. Surgical resection remains the cornerstone of treatment for pancreatic diseases such as PDAC, RCC metastasis, and multifocal IPMN. Whistal may balance oncologic control with pancreatic function preservation. Though infrequent, it is practiced and reported in literature. Methods With IRB approval, a retrospective review of a prospective database (Aug 1999-Mar 2024) identified Whistal cases, categorized as staged Whistal (SW) or concomitant whistal (CW). Perioperative outcomes were assessed via Clavien-Dindo and ISGPS. A PubMed search identified reported middle segment pancreatectomy (Whistal) cases. Results Of 2008 resections (Aug 1999-Mar 2024), 5 were Whistals (3 CW, 2 SW) for PDAC (n = 3), RCC (n = 1), IPMN (n = 1), and bile duct stricture (n = 1). Rates for major morbidity, POPF, and DGE were each 40%. Literature review found 26 papers reporting 52 additional Whistal cases. Conclusion Whistal is safe for select patients, but wider adoption and long-term data are needed to confirm its efficacy.

Background: Despite advances in surgical techniques and perioperative care, pancreatic resections such as pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) remain high-risk procedures. Postoperative complications significantly impact morbidity, mortality, and patient quality of life. Methods: This narrative review summarizes recent literature on major complications following pancreatic surgery, including postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), and post-pancreatectomy hemorrhage (PPH), with an emphasis on incidence, risk factors, outcomes, and current preventive strategies. Results: POPF is a leading complication, occurring in 5–22% of cases and often linked with sepsis and hemorrhage. Key risk factors include high BMI, soft pancreatic texture, and small duct size. Preventive measures like Pasireotide, modified anastomosis techniques, and neoadjuvant therapy show variable success. DGE affects up to 57% of PD patients and is associated with prolonged recovery; antecolic reconstruction and erythromycin may reduce incidence. PPH, though less frequent (3–13%), can be life-threatening, particularly when secondary to POPF. Endovascular approaches are now favored for late arterial bleeding. Other complications include wound infections, abscesses, bile leaks, and pulmonary issues, all contributing to extended hospital stays and diminished quality of life. Conclusions: Pancreatic surgery continues to carry significant risks, with POPF, DGE, and PPH being the most impactful complications. While multiple interventions have shown promise, standardized protocols and predictive tools are still needed. Surgery should be performed in high-volume centers with experienced multidisciplinary teams to optimize outcomes.