Faculty Bibliography

BACKGROUND:Although main duct (MD) and branch duct (BD) IPMNs differ in preoperative risk of malignant transformation, it remains unclear whether ductal subtype influences outcomes once invasive carcinoma develops and is resected. We compared recurrence and survival outcomes between these subtypes. METHODS:We identified patients with resected IPMN-derived pancreatic ductal adenocarcinoma (PDAC) from three institutions. Overall survival (OS) and recurrence-free survival (RFS) were estimated using Kaplan-Meier methods and compared with log-rank tests. Multivariable Cox regression models adjusted for age, T-stage, N-stage, histologic subtype, and adjuvant chemotherapy. RESULTS:Among 136 patients, 106 (78%) had MD-derived and 30 (22%) had BD-derived IPMN-associated PDAC. Median OS was 36.6 months and did not differ by subtype on log-rank (p = 0.472) or multivariable analysis (HR 0.45, 95% CI 0.15-1.31; p = 0.143). Median RFS was 41.8 months without significant difference by subtype on log-rank (p = 0.362) or adjusted analysis (HR 0.56, 95% CI 0.21-1.46; p = 0.234). CONCLUSIONS:In patients with resected IPMN-derived PDAC, ductal subtype was not significantly associated with OS. While clinically meaningful differences in RFS cannot be excluded, these findings suggest that once invasive cancer arises and is resected, ductal subtype alone may not provide additional prognostic information.

BACKGROUND:Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas present a broad spectrum of biological behavior, ranging from benign to malignant. Their management poses significant ethical dilemmas, particularly concerning diagnostic uncertainty, the risk of overdiagnosis and overtreatment, and resource allocation. METHODS:This qualitative study employed a constructivist approach to explore the ethical challenges faced by surgeons in managing IPMNs. Data were collected through focus group meetings (FGMs) with members of an expert working group at the Verona Evidence-Based Meeting on IPMNs (2020). Discussions were analyzed to identify key ethical concerns. RESULTS:The analysis highlighted several major ethical concerns: (1) decision-making under diagnostic uncertainty, (2) ethical challenges in patient communication, (3) overdiagnosis and over-surveillance due to defensive medicine and patient anxiety, (4) overtreatment through unnecessary surgery, and (5) issues of distributive justice in access to care and healthcare resource utilization. Participants emphasized the difficulty of balancing transparency with the need to minimize psychological distress in patients, as well as the challenge of applying international guidelines in diverse healthcare settings. CONCLUSIONS:Ethical decision-making in IPMN management requires balancing the risks of malignancy with the potential harms of overtreatment, while also considering patient autonomy and resource limitations. Enhancing decision-support tools, improving surgeon training in communication, and refining clinical guidelines to incorporate ethical considerations may help address these challenges. Further research is needed to develop strategies for more individualized and patient-centered care.

BACKGROUND:As a 6-month waiting period is required to receive exception points to prioritize patients with hepatocellular carcinoma (HCC) for liver transplantation, prompt addition to the waitlist is critical in access to LT. METHODS:Using Epic Cosmos data on patients with HCC referred for LT 1/2018-10/2024, we used modified Poisson regression to calculate rates of waitlisting. Center-level and individual (socioeconomic, geographic, and insurance) factors were measured among those who progressed. RESULTS:Among 11,422 HCC patients referred for LT at 70 centers, with median age 63 [IQR: 58, 68], 71.5% initiated evaluation and, of those who began evaluation, 57.6% were waitlisted for LT. Of those referred, patients who were older (age 70+ vs. 51-60; RR 0.77, 95% CI: 0.65-0.90, p < 0.001), on Medicaid (0.83, 95% CI: 0.71-0.97, p = 0.02), never-married (0.82, 95% CI: 0.73-0.91, p < 0.001), or low SES (Q4: 0.87, 95% CI: 0.77-0.97, p = 0.002) had lower rates of waitlisting. Among waitlisted patients, median time from referral was 3.3 months [IQR: 2.0, 5.3]. Despite adjustment for patient level covariates, there was high center-level variation in rate of waitlisting within 12 months; 13% of centers listed patients at a rate ≥ 20% below the national median. CONCLUSION/CONCLUSIONS:Only a fraction of referred patients with HCC are waitlisted for LT. High variation in access to waitlisting based on non-clinical factors suggests barriers to waitlisting that must be addressed. Centers should focus on interventions to reduce barriers to waitlisting in patients with HCC.

BACKGROUND:Advances in pancreatic cancer surgery involve hepatotoxic chemotherapies and hepatic vasculature resections, increasing the risk of clinically relevant postpancreatectomy liver injury. The study aimed to analyze the incidence and impact of clinically relevant postpancreatectomy liver injury after pancreatectomy with hepatic vessel resection. METHODS:In this single-institutional study, patients undergoing pancreatectomy with resection of hepatic vessels (portal vein/superior mesenteric vein, celiac axis, and hepatic arteries) were analyzed. Arterial lactate, total bilirubin, alanine aminotransferase, aspartate aminotransferase, international normalized ratio, and Doppler ultrasound-derived resistive index were assessed postoperatively. Postoperative outcomes were assessed through 90 days. Clinically relevant postpancreatectomy liver injury was defined as American Association for the Study of Liver Diseases-defined liver failure and/or need for invasive treatment of liver complications. RESULTS:Among 116 patients (67% portal vein/superior mesenteric vein resection alone, 7% celiac axis/hepatic arteries alone, 26% portal vein/superior mesenteric vein + celiac axis/hepatic artery resection), 15 (13%) developed clinically relevant postpancreatectomy liver injury. Mortality was significantly higher in the clinically relevant postpancreatectomy liver injury group (47% vs 3%; P < .001). The proper hepatic artery resistive index was lower in the clinically relevant postpancreatectomy liver injury group (0.52 vs 0.65; P = .034), whereas the following 48-hour-peak blood tests were significantly higher in this group: Lac, bilirubin, aspartate aminotransferase, and alanine aminotransferase (all P < .01). Combined portal vein/superior mesenteric vein + celiac axis/hepatic arteries and elevated alanine aminotransferase 48-hour peak above 1680 U/L remained significantly associated with the occurrence of clinically relevant postpancreatectomy liver injury in multivariable analyses. Forty percent of clinically relevant postpancreatectomy liver injury occurred in the absence of vascular complications. CONCLUSION/CONCLUSIONS:Clinically relevant postpancreatectomy liver injury is associated with significant mortality. Low resistive index and markedly elevated biochemical markers within the first 48 hours correlate with clinically relevant postpancreatectomy liver injury and may be used to trigger earlier intervention. Given the associated morbidity and mortality, defining, preventing, and mitigating clinically significant postpancreatectomy liver injury is of the utmost importance.

BACKGROUND:Robotic pancreaticoduodenectomy (RPD) is increasingly performed in the United States. Understanding factors associated with safe adoption of RPD is critical to reducing perioperative mortality during the learning curve. METHODS:Using the Epic Cosmos database, the study identified adult patients (age ≥18 years) who underwent pancreaticoduodenectomy (PD) between 2019 and 2025. Modified Poisson regression was used to assess factors associated with 30-day mortality using adjustment for age, sex, race, ethnicity, insurance, marital status, rural/urban residence, socioeconomic status, and diagnosis. Among surgeons performing two or more RPDs, mortality trends were analyzed across case-number thresholds. Mortality risk was assessed by cumulative RPD and open PD (OPD) experience, with adjustment for age and diagnosis. RESULTS:Among 23,995 patients with a median age of 69 years (interquartile range [IQR], 62-75 years), 1578 (6.6 %) underwent RPD. Use of RPD increased from 4% of PD in 2019 to 10% in 2025. The 30-day mortality was higher for RPD than for OPD (2.7 % vs 2.0 %; adjusted relative risks [aRR], 1.43 (IQR, 1.02-1.95; p = 0.029). In RPD, mortality decreased with increasing surgeon prior experience: 3.9 % (Q1: 0-1 cases), 3.9 % (Q2: 2-4 cases), 2.22 % (Q3: 5-8 cases), 2.67 % (Q4: 9-18 cases), 0.92 % (Q5: 19-71 cases). Increased RPD experience was associated with decreased mortality (per doubling RPD experience: aRR, 0.78 (95 % confidence interval [CI], 0.63-0.96; p = 0.02). The patients who underwent PD between 2023 and 2025 showed no adjusted increase in mortality with robotic technique (aRR, 1.04; 95 % CI, 0.61-1.65; p = 0.85). CONCLUSIONS:Nationwide, adoption of RPD is associated with increased 30-day mortality, which decreases substantially with increasing surgeon RPD experience. These findings suggest that structured, competency-based training pathways are needed to ensure safe dissemination of novel technology, including RPD.

BACKGROUND:Management of intraductal papillary mucinous neoplasms (IPMNs) requires choosing between surgical resection and active surveillance, yet current diagnostic tools cannot reliably distinguish which lesions harbor high-grade dysplasia or invasive cancer. As a result, many patients undergo major pancreatic surgery for low-grade disease, while others are observed until progression emerges. This uncertainty contributes to substantial variation in surgeon risk estimates, intervention thresholds, and treatment recommendations. Patients likewise differ in their tolerance for cancer risk, views on surgical morbidity, perceived burden of ongoing surveillance, and desired role in decision-making, making IPMN a distinctly preference-sensitive clinical scenario. Although recent international guidelines acknowledge the importance of incorporating patient values into management decisions, practical frameworks for doing so remain underdeveloped. METHODS:We performed a narrative review of the literature examining sources of uncertainty in IPMN management, variation in surgeon and patient risk perception, and existing approaches to shared decision-making (SDM) in preference-sensitive surgical decisions. We also evaluated communication strategies and decision-support tools relevant to improving decision quality in the setting of uncertain malignant potential. RESULTS:Evidence demonstrates substantial heterogeneity in both clinician and patient interpretation of malignancy risk, operative morbidity, and acceptable thresholds for surgical intervention. Surgeons and patients often weigh competing risks diff erently, contributing to variation in management recommendations even when clinical characteristics are similar. SDM provides a structured approach to integrating individualized malignancy risk estimates, discussion of treatment trade-off s, and elicitation of patient values. Conceptual frameworks and emerging decision-support tools suggest that SDM may improve calibration of risk perception, reduce unwarranted variation in care, and enhance alignment between treatment decisions and patient preferences. CONCLUSIONS:IPMN management represents a high-stakes clinical decision made under conditions of incomplete information. SDM off ers a pragmatic strategy to integrate clinical evidence with patient values when choosing between resection and surveillance. Incorporating SDM into routine IPMN care may improve decision quality, promote transparency in risk communication, and support more patient-centered recommendations while preserving clinical judgment.