Tiziana Marchese

Background: Frailty is an important determinant of postoperative outcomes after pancreatic surgery. However, available assessment instruments are heterogeneous and may inadequately capture the interaction between patient vulnerability, nutritional status, body composition, and procedure‐specific risk. This systematic review evaluated frailty assessment tools in pancreatic surgery and proposed a conceptual pancreas‐specific framework for surgical vulnerability assessment. Methods: A systematic review was conducted according to PRISMA 2020 guidelines. PubMed/MEDLINE, Embase, Scopus, Web of Science, and Google Scholar were searched for studies published between January 2016 and April 2026 evaluating frailty in adult patients undergoing pancreatic resection. Findings were primarily synthesized narratively because of substantial methodological heterogeneity. An exploratory subgroup meta‐analysis was restricted to studies using the Modified Frailty Index that reported adjusted effect estimates for major morbidity or short‐term mortality. Results: Twenty studies involving more than 150,000 patients were included. The Modified Frailty Index was the most frequently used instrument, followed by the Hospital Frailty Risk Score. Frailty was generally associated with increased postoperative morbidity, major complications, mortality, prolonged hospitalization, non‐home discharge, and functional decline, although the extent of confounding control varied across studies. Several associations persisted in adjusted analyses, whereas other findings were supported only by unadjusted comparisons. In an exploratory subgroup meta‐analysis restricted to adjusted estimates from Modified Frailty Index studies, greater mFI‐defined frailty burden was associated with major morbidity (pooled OR 1.60, 95% CI 1.27–2.01; I ² = 53%) and short‐term mortality (pooled OR 1.31, 95% CI 1.16–1.48; I ² = 0%), although these findings remain hypothesis‐generating because of substantial methodological heterogeneity. However, most tools primarily reflect comorbidity burden and incompletely capture nutritional status, sarcopenia, obesity, and pancreas‐specific operative risk. Current evidence suggests that surgical vulnerability in pancreatic resection results from the interaction between patient‐related, nutritional‐, body‐composition, and procedure‐related factors rather than frailty alone. Conclusions: Frailty is clinically relevant to postoperative risk assessment in pancreatic surgery and should be incorporated into preoperative evaluation. Existing tools, however, inadequately capture the multidimensional nature of surgical vulnerability. We therefore propose the PANFRAIL framework, a conceptual, hypothesis‐generating model integrating frailty, nutritional status, body composition, procedure‐related complexity, and pancreas‐specific risk to guide future development of pancreatic surgery‐specific risk assessment strategies.

Pancreatoduodenectomy (PD) is one of the most challenging surgical procedures among abdominal surgeries. The most common complication after PD is postoperative pancreatic fistula (POPF), which can be severe and entail other complications, such as post-pancreatectomy hemorrhage (PPH), which can be fatal. Several surgical techniques have been proposed to reduce the incidence of POPF and PPH. In this study, we describe inframesocolic pancreatic anastomosis, which involves segregating the pancreatic anastomosis into the inframesocolic area by mobilizing the pancreatic remnant and creating a small window into the transverse mesocolon. This surgical technique was performed in 17 patients, with promising results in terms of delayed PPH prevention. In particular, we had only one case of PPH that was successfully treated by placing a stent into the SMA. No other bleeding events were reported, even in cases of anastomotic leakage. In the context of mitigation strategies, this technique might be efficient in reducing the incidence of delayed PPH due to leakage of pancreatic juice into the supramesocolic area and consequent vascular erosion.

Background Postoperative pancreatic fistula (POPF), particularly clinically relevant grades B and C (CR-POPF), remains a major source of morbidity following pancreatoduodenectomy (PD). Robotic pancreatoduodenectomy (RPD) has emerged as a minimally invasive alternative to open PD (OPD), potentially offering technical advantages that reduce complication rates. However, the true impact of RPD on CR-POPF remains unclear. Methods A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines, including studies published between January 2010 and June 2025. PubMed, Embase, Scopus, and Web of Science were queried for randomized trials, cohort studies, and propensity score-matched (PSM) analyses comparing RPD and OPD concerning CR-POPF as defined by the International Study Group on Pancreatic Surgery (ISGPS). Study quality was assessed using the Newcastle–Ottawa Scale, and the certainty of evidence was graded using the GRADE framework. Results Thirty-two studies encompassing over 24 000 patients were included, of which approximately 5 000 underwent RPD and 19 600 underwent OPD. The pooled analysis showed a significantly lower incidence of CR-POPF in the RPD group (OR 0.60, 95% CI 0.51–0.67; p < 0.001), with moderate heterogeneity (I² = 56%). Subgroup analysis indicated that the benefit was limited to high-volume centers (≥ 20 RPD annually) and matched studies, while the two available randomized trials did not show a significant difference. Conclusions RPD is associated with a reduced incidence of CR-POPF when performed in experienced, high-volume centers. These findings support the selective implementation of RPD within structured training and quality-control programs. Further high-quality randomized trials are needed to validate these results and explore long-term outcomes. Graphical Abstract

Background and Objectives: Various publications have compared outcomes among open (OPDs), laparoscopic (LPDs), and robotic pancreaticoduodenectomies (RPDs); however, the number of randomized controlled trials (RCTs) remains limited. This study aims to conduct a systematic review and analyze the outcomes between these approaches from randomized controlled trials. Materials and Methods: We performed a systematic literature search across PubMed/MedLine, Cochrane Library, ClinicalTrials.gov, and Google Scholar to identify relevant RCTs. The systematic review was conducted using the reporting items for systematic reviews and network meta-analyses guidelines (PRISMA-NMA) and registered in Prospero (CRD420251024475). For statistical analysis R software (version 4.3.2) was used. Results: Eight RCTs involving 1416 patients (706 OPDs, 600 LPDs, 110 RPDs) were included. LPD had a significantly longer operative time than OPD, while RPD showed no significant difference compared to OPD. Blood loss was reduced in both minimally invasive approaches. LPD showed a higher R0 resection rate and lower pancreatic fistula rate, whereas RPD had the lowest mortality. No significant differences were observed in major complications, reoperation, or readmission. LPD shortened hospital stay; RPD showed no difference. Conclusions: Although open pancreaticoduodenectomy remains a well-established standard, both laparoscopic and robotic approaches offer safe alternatives with distinct advantages. LPD is associated with shorter hospital stay and lower pancreatic fistula rates, whereas RPD demonstrates the lowest mortality. The lack of direct randomized comparisons between LPD and RPD highlights the need for further head-to-head trials.

Background: To date, no standardized protocols nor a quantitative assessment of the near-infrared fluorescence angiography with indocyanine green (NIR-ICG) are available. The aim of this study was to evaluate the timing of fluorescence as a reproducible parameter and its efficacy in predicting anastomotic leakage (AL) in colorectal surgery. Methods: A consecutive cohort of 108 patients undergoing minimally invasive elective procedures for colorectal cancer was prospectively enrolled. The difference between macro and microperfusion DeltaT was obtained by calculating the timing of fluorescence at the level of iliac artery division and colonic wall, respectively. Results: Subjects with a DeltaT higher 15.5 s had a higher tendency to develop an AL (p lower 0.01). The DeltaT/heart rate interaction was found to predict AL with an odds ratio of 1.02 (p lower 0.01); a cut-off threshold of 832 was identified (sensitivity 0.86, specificity 0.77). Perfusion parameters were also associated with a faster bowel motility resumption and a reduced length of hospital stay. Conclusions: The analysis of the timing of fluorescence provides a quantitative, easy evaluation of tissue perfusion. A DeltaT/HR interaction higher 832 may be used as a real-time parameter to guide surgical decision making in colorectal surgery.

Background: To date, no standardized protocols nor a quantitative assessment of the near-infrared fluorescence angiography with indocyanine green (NIR-ICG) are available. The aim of this study was to evaluate the timing of fluorescence as a reproducible parameter and its efficacy in predicting anastomotic leakage (AL) in colorectal surgery. Methods: A consecutive cohort of 108 patients undergoing minimally invasive elective procedures for colorectal cancer was prospectively enrolled. The difference between macro and microperfusion (ΔT) was obtained by calculating the timing of fluorescence at the level of iliac artery division and colonic wall, respectively. Results: Subjects with a ΔT ≥ 15.5± 0.5 s had a higher tendency to develop an AL (p < 0.01). The ΔT/heart rate interaction was found to predict AL with an odds ratio of 1.02 (p < 0.01); a cut-off threshold of 832 was identified (sensitivity 0.86, specificity 0.77). Perfusion parameters were also associated with a faster bowel motility resumption and a reduced length of hospital stay. Conclusions: The analysis of the timing of fluorescence provides a quantitative, easy evaluation of tissue perfusion. A ΔT/HR interaction ≥832 may be used as a real-time parameter to guide surgical decision making in colorectal surgery.

Acinar cystic transformation (ACT), also known as ‘acinar cell cystadenoma’, is an uncommon cystic neoplasm of pancreas with unknown malignant potential. This case regards a woman with symptomatic pancreatic head ACT, revealed with pathological exam of specimen after pancreaticoduodenectomy. A 57-years-old patient presented mild hyperbilirubinemia and recurrent cholangitis; she underwent to ERCP, EUS and MRI, and these exams revealed a large cyst of the pancreatic head that caused biliary compression. The discussion of the case by the multidisciplinary group indicated surgical resection. Pancreatic ACT is so rare, and its preoperative diagnosis is difficult. The symptoms of the patients and the features of the cyst are the criteria to choose a surgical resection.