Enrique Toledo

Background: Whether tumor functional status influences postoperative outcomes after left pancreatectomy (LP) for pancreatic neuroendocrine tumors (pNETs) remains unknown. We evaluated the association between functional status, perioperative management, and postoperative outcomes in a prospective nationwide cohort of patients undergoing LP for pNET. Methods: This prespecified analysis of the prospective multicenter SPANDISPAN study included consecutive patients undergoing elective LP at 41 Spanish hospitals between February 2022 and January 2023. Of 98 patients with pNET, functional status was available in 88 (14 functioning and 74 non-functioning tumors). Perioperative characteristics, spleen preservation, and postoperative outcomes were compared according to tumor functional status. Results: Spleen preservation was performed in 28.6% of functioning and 18.9% of non-functioning tumors (p = 0.472; risk difference 9.7 percentage points, 95% CI [confidence interval] −15.6 to 34.9). Patients with functioning tumors had lower rates of clinically relevant postoperative pancreatic fistula (7.1% vs. 36.5%; p = 0.032; risk difference −29.3 percentage points, 95% CI −46.7 to −12.0), shorter length of hospital stay (median 4 vs. 7 days; p = 0.036), and no 90-day readmissions (0% vs. 31.1%; p = 0.017; risk difference −31.1 percentage points, 95% CI −41.6 to −20.5). Tumor functional status was not significantly associated with the use of spleen-preserving resection. Conclusions: Functional status is associated with clinically relevant differences in postoperative outcomes after LP for pNET. Patients with functioning tumors experienced lower postoperative morbidity than those with non-functioning tumors, whereas no statistically significant association was detected between tumor functional status and spleen preservation. These exploratory findings suggest that tumor functional status may warrant consideration as an additional factor in perioperative risk stratification and patient counseling, pending confirmation in larger, adequately powered studies; spleen preservation should continue to be guided by established oncological criteria.

Background: Minimally invasive left pancreatectomy (MILP) has become the preferred approach to treat lesions of the pancreatic body and tail. However, the procedure may require conversion to open surgery, with reported conversion rates varying widely in the literature. This study aims to evaluate the incidence, causes, and clinical outcomes associated with conversion to open surgery in a prospective multicenter series. Methods: The SPANDISPAN Project is a prospective, multicenter study conducted at 41 Spanish hospitals from February 2022 to January 2023. Patients were divided into conversion and nonconversion groups to identify predictors using univariate and multivariate logistic regression models. Results: Of 313 recorded left pancreatectomies, 217 (69.3%) were MILP procedures. The conversion rate was 10.6%. Reasons for conversion included hemorrhage (60.9%) and intraoperative technical difficulties (39.1%). Multivariable analysis identified intraoperative blood loss (OR 1.65 per 100‐mL increment; p < 0.001) and intraoperative transfusion (OR 7.777; p = 0.012) as independent intraoperative correlates of conversion, reflecting the bleeding‐related process leading to conversion rather than preoperative predictors available for case selection. Low center volume was associated with a higher conversion rate in univariable analysis (14.5% vs. 6%; p = 0.042) with a nonsignificant protective trend for high‐volume centers after multivariable adjustment (OR 0.339; p = 0.075). Although patients who required conversion had longer operative times and hospital stays, there were no significant differences in major complications, postoperative pancreatic fistula, or mortality between the groups. Conclusions: Conversion to open surgery during MILP is primarily driven by intraoperative bleeding‐related events rather than by preoperative patient or tumor characteristics. Treatment at a high‐volume center was associated with a lower conversion rate, although this trend did not reach significance after multivariable adjustment. Conversion was not associated with a significant increase in major morbidity or mortality in this cohort, supporting its use as a proactive safety measure rather than a surgical failure, although the limited number of conversion events warrants a cautious interpretation of this negative finding.

Background/Objectives: Like many other countries, the management of pancreatic cancer in Spain has developed in a fragmented manner. This study analyzes clinical outcomes related to patient volume at different centers after left pancreatectomy (LP). Our goal is to determine whether our practices align with the standards established in the literature and assess whether centralization’s advantages significantly outweigh its disadvantages. Methods: The SPANDISPAN Project (SPANish DIStal PANcreatectomy) is an observational, prospective, multicenter study focused on LP conducted in Spanish Hepato-Pancreato-Biliary (HPB) Surgery Units from 1 February 2022 to 31 January 2023. HPB units were defined as high volume if they performed more than 10 LPs annually. Results: This study included 313 patients who underwent LP at 42 centers across Spain over the course of a year. A total of 40.3% of the procedures were performed in high-volume centers. Significant differences in preoperative variables were only observed in ASA scores, which were higher in the high-volume group. Intraoperatively, minimally invasive surgical techniques were performed more frequently in high-volume centers. Postoperatively, the administration of somatostatin, major complications, and B and C postoperative pancreatic fistula (POPF) were more frequent in low-volume hospitals. Conclusions: The findings revealed that high-volume centers had a higher rate of minimally invasive surgery, lower intraoperative bleeding, fewer complications, and reduced POPFs compared to low-volume centers. However, it is important to note that low-volume centers still demonstrated acceptable outcomes. Thus, the selective referral of more complex laparoscopic procedures could initiate a gradual centralization of surgical practices.

Background/Objectives: Like many other countries, the management of pancreatic cancer in Spain has developed in a fragmented manner. This study analyzes clinical outcomes related to patient volume at different centers after left pancreatectomy (LP). Our goal is to determine whether our practices align with the standards established in the literature and assess whether centralization's advantages significantly outweigh its disadvantages. Methods: The SPANDISPAN Project (SPANish DIStal PANcreatectomy) is an observational, prospective, multicenter study focused on LP conducted in Spanish Hepato-Pancreato-Biliary (HPB) Surgery Units from February 1st, 2022, to January 31st, 2023. HPB units were defined as high volume if they performed more than 10 LPs annually. Results: This study included 313 patients who underwent LP at 41 centers across Spain over the course of a year. 40.3% of the procedures were performed in high-volume centers. Significant differences in preoperative variables were only ob-served in ASA scores, which were higher in the high-volume group. Intraoperatively, minimally invasive surgical techniques were performed more frequently in high-volume centers. Postoperatively, the administration of somatostatin, major com-plications, and B and C postoperative pancreatic fistula (POPF) were more frequent in low-volume hospitals. Conclusions: The findings revealed that high-volume centers had a higher rate of minimally invasive surgery, lower intraoperative bleeding, fewer complications, and reduced POPFs compared to low-volume centers. However, it is important to note that low-volume centers still demonstrated acceptable outcomes. Thus, the selective referral of more complex laparoscopic procedures could initiate a gradual centralization of surgical practices.

Liver transplantation (LT) is a curative treatment for early-stage hepatocellular carcinoma (HCC) unsuitable for surgical resection. However, tumor recurrence (TR) rates range from 8% to 20% despite strict selection criteria. The validation of new prognostic tools, such as pre-MORAL or RETREAT risks, is necessary to improve recurrence prediction. A retrospective study was conducted at Marqués de Valdecilla University Hospital in Cantabria, Spain, between 2010 and 2019 to determine the rate of TR in LT patients and identify associated factors. Patients with liver-kidney transplantation, re-transplantation, HIV infection, survival less than 90 days, or incidental HCC were excluded. Data on demographic, liver disease-related, LT, and tumor-related variables, as well as follow-up records, including TR and death, were collected. TR was analyzed using the Log-Rank test, and a multivariate Cox regression analysis was performed. The study was approved by the IRB of Cantabria. TR occurred in 13.6% of LT patients (95% CI = 7.3–23.9), primarily as extrahepatic recurrence (67%) within the first 5 years (75%). Increased TR was significantly associated with higher Body Mass Index (BMI) (HR = 1.3 [95% CI = 1.1–1.5]), vascular micro-invasion (HR = 8.8 [1.6–48.0]), and medium (HR = 20.4 [3.0–140.4]) and high pre-MORAL risk (HR = 30.2 [1.6–568.6]). TR also showed a significant correlation with increased mortality. Conclusions: LT for HCC results in a 13.6% rate of tumor recurrence. Factors such as BMI, vascular micro-invasion, and medium/high pre-MORAL risk are strongly associated with TR following LT.