Background: Minimally invasive pancreatic resections (MIPRs) have been shown to be safe and feasible, but there is still a lack of high-level evidence on oncological outcomes for cephalic pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to compare the oncological outcomes of patients undergoing MIPR and open pancreatic resection (OPR) for pancreatic head cancer in a single high-volume center. Methods: Data from a prospectively collected database of patients who underwent radical-intent surgery for resectable and borderline resectable PDAC of the head at our institution between January 2013 and May 2023 were retrieved and analyzed, comparing the surgical and oncological outcomes of MIPR and OPR, using a propensity score matching analysis. Results: In the study period, 220 patients were selected. After matching, a total of 81 MIPRs and 81 OPRs were compared. No difference was found regarding R0 rate (OPR 83.9% vs. MIPR 74.1%, p = 0.122). Median overall survival (24 and 31 months for the OPR and MIPR groups, respectively; log rank p = 0.665) and disease-free survival (12 and 21 months for the OPR and MIPR groups, respectively; log rank p = 0.118) did not differ between the groups. The MIPR group was associated with a greater number of harvested lymph nodes (22 vs. 16, p = 0.0008), longer operative time (565 vs. 420 min, p < 0.0001), and shorter length of stay (12 vs. 18 days; p = 0.0001). No differences between the groups were found regarding all other postoperative and pathological outcomes. Conclusions: Regarding oncological outcomes, MIPR appeared to be comparable to OPR for treating patients with PDAC of the head. Despite an increased operative time, MIPR was associated with a greater number of LNs harvested and a shorter length of stay.

Background: Despite benefits during open pancreatoduodenectomy (PD), the artery-first approach (AFA) during minimally invasive PD (MIPD) has been poorly investigated. Methods: Data of consecutive patients undergoing MIPD (both laparoscopic (LPD) and robotic (RPD)) from 2020 to 2024 for pancreatic cancer (PC) were prospectively collected and retrospectively analyzed, comparing the surgical and oncological outcomes of LPD with right AFA and RPD with posterior AFA. The rate of ineffective AFA (IAFA), defined in the case of excessive resection time, estimated blood loss, or conversion to laparotomy, was also investigated. Results: 71 patients undergoing MIPD were selected (32 LPD and 39 RPD). Baseline patients’ characteristics only differed for a higher rate of neoadjuvant treatment in LPD and RPD groups, respectively (23.1% vs. 0%, p = 0.0036). No patients underwent conversion. R0 resection was obtained in 74.6% of patients. No difference between the groups was found regarding intraoperative, postoperative, and oncological outcomes except for a greater number of lymph nodes harvested in RPD (24 vs. 17, p = 0.023). IAFA was observed in 12.7% of patients, without difference between the groups (9.4 vs. 15.4%, p = 0.499, in LPD and RPD, respectively). Conclusions: MIPD with AFA was feasible and safe in patients affected by PC. RPD using posterior AFA had a higher number of lymph nodes retrieved when compared to LPD using right AFA. RPD has provided subjective advantages for the surgeon in terms of handling, safety, and reproducibility, although these have not translated into better outcomes.

Disappearing liver metastases (DLMs) remain a challenging problem in the management of colorectal liver metastases (CRLMs). Although modern systemic therapy may produce complete radiological responses, radiological disappearance does not reliably indicate complete pathological response. Conversely, mandatory treatment of every original metastatic site may cause unnecessary parenchymal sacrifice when a lesion is no longer identifiable on hepatobiliary contrast-enhanced magnetic resonance imaging or intraoperative ultrasonography. Current strategies—including treatment of the presumed site, selective pre-treatment fiducial marking where feasible and considered appropriate, and structured surveillance—therefore involve important trade-offs. We propose a hypothesis-generating, lesion-specific strategy for a narrowly selected subgroup: thermal ablation before systemic therapy of one or a few small CRLM, preferably no larger than 2 cm, considered at higher anticipated risk of post-treatment loss of localization. Selection should distinguish the probability of radiological disappearance from its clinical consequences. Candidate lesions should be clearly and unambiguously identifiable on high-quality baseline imaging, safely accessible for ablation with a margin greater than 5 mm and ideally approximately 10 mm, and located outside any planned resection field, particularly when their depth or anatomical position would make empirical treatment difficult after disappearance. Recent randomized evidence supports thermal ablation as definitive local therapy for appropriately selected small CRLM but does not validate the proposed pre-systemic treatment sequence. This approach should not delay urgently required systemic therapy, compromise biological selection, or be used indiscriminately in high-volume, rapidly progressive, uncontrolled extrahepatic, or technically unsuitable disease. It is also generally unnecessary when the lesion is encompassed by a planned resection or total hepatectomy within a liver transplantation pathway. Upfront ablation may secure local control while the target remains visible, preserve liver parenchyma, and avoid premature interruption of systemic therapy or acceleration of surgery solely because a responding lesion is becoming radiologically occult. However, it may cause overtreatment and procedural morbidity and remains unsupported by prospective comparative evidence. A multicentre feasibility study, followed by prospective comparison with contemporary standard sequencing and, where feasible and considered appropriate, fiducial-based localization, is required to evaluate this strategy.