A spatial atlas of chemoradiation therapy in pancreatic cancer identifies cellular and microenvironmental determinants of persister populations.

The molecular pathways involved in the response to radiation therapy in pancreatic ductal adenocarcinoma (PDAC) remain poorly understood. We aimed to elucidate the adaptive mechanisms and cellular interactions within PDAC to radiation therapy (RT). We constructed a transcriptomic landscape of the cellular subtypes and spatially resolved neighborhoods from 50 patient samples, including 16 longitudinally matched single cell RNA sequencing and 34 spatial transcriptomics specimens.

The Landmark Series: Neoadjuvant Therapy for Resectable Pancreatic Cancer.

Pancreatic ductal adenocarcinoma (PDAC) remains a malignancy with limited 5-year overall survival, but recent advances in maximizing chemotherapy delivery has offered some improvement across all stages. Delivery of induction chemotherapy for localized PDAC has several putative benefits, including early treatment of occult metastases, pragmatically ensuring all patients receive systemic therapy, and improved R0 resection rates. While neoadjuvant therapy has become widely accepted in borderline resectable clinical stage, its role in patients with resectable disease is less clear.

Institutional learning curve and factors of prolonged operation time of robotic distal pancreatectomy: An analysis of an initial 117 cases.

Background: The granular methods by which centers can safely implement and effectively expand robotic distal pancreatectomy (RDP), including those related to appropriate patient selection during the learning curve period, remain unclear. This study aimed to verify that our strategic robotic surgical oncology program effectively implemented RDP as standard practice and to identify factors associated with prolonged operation time.

Materials And Methods: We performed a detailed analysis of the intraoperative and short-term outcomes of consecutive patients (October 2018-September 2023) undergoing RDP at our center, beginning with the first patient in our program.

5x-Multiplier vs 3-Tier Model for Discharge Opioid Prescriptions After Intra-Abdominal Cancer Surgery: Randomized Clinical Trial Protocol.

Background: Surgeons provide up to 10% of total opioid prescriptions across all specialties, and more than one-third of surgeon-prescribed medications are opioids. Patient-reported opioid consumption and risk of persistent opioid use beyond the postoperative recovery period correlate with the initial opioid quantity prescribed at discharge. Interventions to reduce postoperative opioid prescribing have demonstrated no adverse effects on pain control or increased need for prescription refill; however, in the absence of standardized prescription protocols, opioid prescribing practices vary widely.

Hepatobiliary Tumor Board: A Multidisciplinary Review of Challenging Cases.

Multidisciplinary case conferences have been shown to improve patient outcomes. However, such case conferences may be unavailable in some settings. This multidisciplinary discussion of 4 challenging hepatobiliary cases was presented at the 2023 Society of Advanced Body Imaging Annual Meeting in Dallas, TX.

Robotic Approach to Oncologic Pancreatoduodenectomy in a Case with an Aberrant Hepatic Artery Originating from the Superior Mesenteric Artery.

Background: Robotic pancreatoduodenectomy (RPD) has been increasingly performed, but maintaining oncological operative standards and safety remains challenging. An aberrant hepatic artery originating from the superior mesenteric artery (SMA), most commonly seen as a replaced right hepatic artery (rRHA), is present in approximately 16% of patients with pancreatoduodenal malignancies. The presence of the rRHA is a known risk factor for technically challenging RPD, and injury to this artery increases the risk of postoperative complications.

Persistent Improvement in Opioid Perceptions and Prescribing for Cancer Surgery: 5-Year Follow-Up.

Background And Objectives: We previously reported that implementation of a department-wide opioid education program led to post-education improvements in opioid perceptions and prescription recommendations, with one-month and one-year retention. With ongoing programmatic and quality improvement efforts, we sought to re-evaluate the retention of these improvements five years after initial efforts.

Methods: Attending surgeons, clinical fellows, and advanced practice providers were surveyed five years after implementation of a comprehensive, departmental opioid reduction framework in August 2018.

Advanced gallbladder cancer (T3 and T4): insights from an international multicenter study.

Background: Surgical resection is the only curative treatment of gallbladder cancer (GBC). However, the role of oncologic extended resection (OER) in advanced GBC (T3/T4) remains unclear. This study aimed to evaluate the effect of OER in patients with advanced GBC.

Repeat versus Single Quadratus Lumborum Block to Reduce Opioids After Open Pancreatectomy (RESQU-BLOCK): A Randomized Clinical Trial.

Objective: The primary aim was to compare the proportion of opioid-free discharges between two postoperative analgesia bundles distinguished by receipt of a single-block versus a second, "rescue" block. Secondary outcomes included differences in discharge prescription oral morphine equivalents (OME) and patient-reported outcomes.

Summary Background: After a preoperative quadratus lumborum (QL) block, our historical discharge opioid prescription for open pancreatectomy was 300mg OME, with only 5% patients discharged opioid-free.

Parenchymal-sparing hepatectomy vs single-stage major hepatectomy for bilateral colorectal liver metastases: a higher rate of microscopically positive margins is not associated with increased local recurrence after parenchymal-sparing hepatectomy.

Background: Surgeons may consider parenchymal-sparing hepatectomy (PSH) or major hepatectomy (MH) for patients with bilateral colorectal liver metastases (CLMs). This study aimed to evaluate the outcomes between PSH and MH for patients with extensive, bilateral CLMs.

Methods: A prospective database was queried for patients with ≥5 bilateral CLMs who underwent R0-intent initial single-stage hepatectomy (1998-2022).

KRAS mutation detection by liquid biopsy for pancreatic ductal adenocarcinoma.

The clinical utility of liquid biopsy (LB) for pancreatic ductal adenocarcinoma (PDAC) remain understudied. Our single-institution cohort of 311 PDAC patients with non-tumor tissues informed LB found 81.2% positivity (N = 186) in metastatic cases and in 52.

Advancing Robotic Liver Resection: The Sling Technique for Improved Hepatic Retraction.

Hepatic surgery, including laparoscopic liver resection, is well codified with difficulty scales on the basis of lesion position, particularly in the posterior segments, lesion size, and underlying liver disease. These scores are transposable to robotic hepatic surgery. Tumors in segment 7 are particularly challenging to expose and are classified as difficult to access.

Software-based versus visual assessment of the minimal ablative margin in patients with liver tumours undergoing percutaneous thermal ablation (COVER-ALL): a randomised phase 2 trial.

Background: Tumour coverage with an optimal minimal ablative margin is crucial for improving local control of liver tumours following thermal ablation. The minimal ablative margin has traditionally been assessed through visual inspection of co-registered CT images. However, rates of local tumour control after thermal ablation are highly variable with visual assessment.

Optimizing Outcomes in Gallbladder Cancer: Identifying Predictors of Futile Up-Front Surgery in a Global Multi-center Study.

Background: Gallbladder cancer (GBC) has a poor prognosis, particularly in advanced stages, with surgery often offering limited survival benefit. This study aimed to identify risk factors for futile surgery (FS), defined as procedures followed by early recurrence or death.

Methods: An international cohort of 788 patients who underwent up-front GBC surgery across 18 centers was analyzed.

Robotic Central Pancreatectomy: Patient Selection and Surgical Approach.

Central pancreatectomy (CP) is one of the parenchyma-sparing approaches proposed for low-grade tumors. CP has a lower incidence of diabetes compared with distal pancreatectomy, but may harbor risks of positive distal pancreatic margin, inadequate lymph node (LN) removal, and pancreatic fistula from the pancreaticojejunal anastomosis. Given the reported oncologic safety, we selectively perform CP for small pancreatic neuroendocrine tumors (pNETs) that are localized to the pancreatic neck.

Improved Outcomes Following Resection of Perihilar Cholangiocarcinoma: A 27-Year Experience.

Background: Resection of perihilar cholangiocarcinoma (pCCA) is associated with significant perioperative morbidity and mortality. We sought to evaluate surgical outcomes following resection of pCCA over time.

Methods: Patients who underwent curative-intent resection with hepatectomy for pCCA at a single institution were divided into two cohorts based on date of resection: past cohort (1996-2013), and recent cohort (2014-2023).

Carbohydrate antigen 19-9 (CA19-9) response after induction FOLFIRINOX for locally advanced pancreatic cancer identifies patients who may benefit from surgical exploration: multicentre, observational cohort study.

Background: Which patients with locally advanced pancreatic cancer may benefit from surgical exploration after induction treatment remains debated. The aim of this retrospective cohort study was to identify independent factors for overall survival after surgical exploration for locally advanced pancreatic cancer, which are available at restaging after induction therapy.

Methods: Consecutive patients with locally advanced pancreatic cancer from the Trans-Atlantic Pancreatic Surgery cohort who underwent surgical exploration after FOLFIRINOX as induction chemotherapy were included.

Defining the Role of Adjuvant Radiotherapy for Biliary Tract Cancers: A Site-Specific Propensity-Matched Analysis.

: Biliary tract cancers (BTCs) have distinct tumor biology but share a poor prognosis, with a 5-year-survival-rate of 5-19%. Surgical resection is the only potential cure, but recurrences are common. The role of adjuvant radiotherapy (XRT) remains unclear.

Evolving Paradigms in the Treatment of Oligometastatic Pancreatic Ductal Adenocarcinoma.

Multiple randomized trials have suggested that the addition of comprehensive metastasis-directed therapy to best systemic therapy improves disease control and survival among patients with oligometastatic disease, even for histologies with a high propensity for rapid spread. Here, we review the growing literature supporting the oligometastatic paradigm in pancreatic ductal adenocarcinoma. We summarize key details from nascent institutional series and reflect on the recently reported phase II randomized EXTEND trial.

Associations of KRAS Point Mutations with Survival of Patients Who Underwent Curative-Intent Resection of Colorectal Liver Metastases.

Background: The oncologic significance of specific KRAS point mutations for patients with colorectal liver metastases (CLM) is uncertain. This study aimed to assess the prognostic impact of KRAS point mutations on patients who underwent surgery for CLM.

Methods: Patients who underwent curative-intent surgery for CLM from 2001 to 2020 were selected for the study.

Impact of Nonhepatectomy Opioid Reduction Efforts on Posthepatectomy Opioid Prescription: Analysis of 2,005 Patients.

Background: Pathway-driven, postpancreatectomy opioid reduction interventions have proven effective and sustainable and may have a "halo effect" on other major abdominal cancer operations. This study aimed to analyze the sequential effects of expanding opioid reduction efforts from pancreatectomy on opioids prescribed after hepatectomy.

Study Design: This was a retrospective cohort study using data from the electronic health record and a prospective quality improvement database for consecutive hepatectomy patients (September 2016 to February 2024).

Propensity Score-Matched Analysis of Liver Venous Deprivation and Portal Vein Embolization Before Planned Hepatectomy in Patients with Extensive Colorectal Liver Metastases and High-Risk Factors for Inadequate Regeneration.

Background: Liver venous deprivation (LVD) is known to induce better future liver remnant (FLR) hypertrophy than portal vein embolization (PVE). The role of LVD, compared with PVE, in inducing FLR hypertrophy and allowing safe hepatectomy for patients with extensive colorectal liver metastases (CLM) and high-risk factors for inadequate hypertrophy remains unclear.

Methods: Patients undergoing LVD (n = 22) were matched to patients undergoing PVE (n = 279) in a 1:3 ratio based on propensity scores, prior to planned hepatectomy for CLM at a single center (1998-2023).