Introduction: Lymph-nodal involvement (N+) represents an adverse prognostic factor after pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC). Preoperative diagnostic and staging modalities lack sensitivity for identifying N+. This study aimed to investigate preoperative carbohydrate antigen 19.9 (CA 19.9) in predicting the N+ stage in resectable-PDAC (R-PDAC). Methods: Patients included in a multi-institutional retrospective database of PDs performed for R-PDAC from January 2000 to June 2021 were analysed. A preoperative laboratory value of CA 19.9 greater than 37 U/l was used in univariate and multivariate logistic regression analysis to determine a possible association with N+. Additionally, different cut-offs of CA 19.9 related to the preoperative clinical T (cT) stage was assessed to evaluate the risk of N+. Results: A total of 2034 PDs from thirteen centres were included in the study. CA 19.9 greater than 37 U/l was significantly associated with higher N+ at univariate and multivariate analysis (P<0.001). CA 19.9 levels greater than 37 U/l were associated with N+ in 75.9%, 81.3%, and 85.7% of patients, respectively, in cT1, cT2, and cT3 tumours and with higher cut-off values for all cT stages. Conclusion: Lymph-nodal involvement is strongly related to preoperative CA 19.9 levels. Specially in patients staged as cT3 the CA 19.9 could represent a valid and easy tool to suspect nodal involvement. Due to these findings, R-PDAC patients with elevated CA 19.9 values should be considered in a more biologically advanced stage.

Background and aims: Previous studies indicated that laparoscopic surgery could improve postoperative outcomes in acute appendicitis, acute cholecystitis, perforated gastroduodenal ulcer, or acute diverticulitis, but some reported opposite results or differences in the magnitude of improvement. A contemporary analysis using propensity score matching that compares outcomes is lacking. Methods: Over a 6-month period, 38 centres (5% of all public hospitals) attending emergency general surgery patients on a 24 h, 7 days a week basis, enroled all consecutive adult patients who underwent laparoscopic surgery or open approach. Results: The study included 2 645 patients with acute appendicitis [32 years (22–51), 44.3% women], 1 182 with acute cholecystitis [65 years (48–76); 46.7% women], and 470 with gastrointestinal tract perforation [65 years (50–76); 34% women]. After propensity score matching, hospital stays decreased in acute appendicitis [open, 2 days (2–4); lap, 2 days (1–4); P<0.001], acute cholecystitis [open, 7 days (4–12); lap, 4 days (3–6); P<0.001], and gastrointestinal tract perforation [open, 11 days (7–17); lap, 6 days (5–8.5); P<0.001]. A decrease in 30-day morbidity was observed in acute appendicitis (open, 15.7%; lap, 9.7%; P<0.001), acute cholecystitis (open, 41%; lap, 21.7%; P<0.001), and gastrointestinal tract perforation (open, 45.2%; lap, 23.5%; P<0.001). A decrease in 30-day mortality was found in acute cholecystitis (open, 8.8%; lap, 2.8%; P=0.013) and gastrointestinal tract perforation (open, 10.4%; lap, 1.7%; P=0.013). Conclusions: This clinically based, multicentre study suggests that an initial laparoscopic approach could be considered not only in patients with acute appendicitis or acute cholecystitis but also in patients with a perforation of the gastrointestinal tract.