Background: The potential long-term survival benefits of surgical resection for synchronous liver-only metastases of pancreatic ductal adenocarcinoma (liver oligo-PDAC) remain controversial. This systematic review and meta-analysis aim to compare the current evidence on long-term survival outcomes between surgical treatment of liver oligo-PDAC and conventional systemic chemotherapy. Materials and methods: A systematic review and meta-analysis were conducted using the PubMed and Scopus databases to identify studies comparing surgery and systemic chemotherapy in terms of long-term survival in oligo-PDAC patients. The search included studies published up to October 2024. The meta-analysis was performed using the Jamovi software. Results: Eleven retrospective studies were selected for a total of 897 patients: 565(63%) underwent synchronous resection of liver metastases and the primary tumor, while 332(37%) received conventional chemotherapy. The majority of patients presented a pancreatic head tumor, and the median number of liver metastases ranged between 1 and 3 in the surgical cohort and 1 and 2 in the nonsurgical cohort. The rate of major surgical complications was 14.4% while the cumulative incidence of postoperative mortality was 2.8%. The median overall survival(OS) in the surgical group ranged from 7.6 to 18.4 months, while a lower value comprised between 6 and 9.9 months was evidenced in the nonsurgical cohort. Six studies were included in the meta-analysis for the OS evaluation, showing significantly better survival outcomes in the surgical group (OR: 0.286, 95% CI: 0.100–0.409; P < 0.0001). According to the Q-test, there was no significant heterogeneity in the true outcomes (Q = 4.063, P = 0.541, I ² = 0 %). A sensitivity analysis, conducted by excluding one study at a time, confirmed the robustness of the meta-analysis findings. Conclusions: Surgical resection of oligo-PDAC may represent a valuable treatment option with potential long-term survival benefits. However, prospective randomized trials are required to further validate these findings.

Background/Objectives: Neo-adjuvant chemotherapy (NACT) is increasingly utilized in Western countries for the treatment of gastric cancer (GC). While its oncologic benefits are well established, its impact on surgical safety and long-term outcomes remain a matter of debate. This study evaluates the real-world effect of NACT on perioperative and oncologic outcomes in a high-volume Western center. Methods: Data from 254 patients who underwent gastrectomy with D2 lymphadenectomy for GC between March 2016 and January 2024 were prospectively collected and retrospectively analyzed. Patients were categorized into an upfront surgery group (n = 144, 56.7%) and a NACT group (n = 110, 43.3%). The primary outcome was to compare the two study groups in terms of perioperative outcomes, as well as overall (OS) and disease-free survival (DFS). Multivariate analyses were conducted to identify factors associated with perioperative complications and long-term survival. Results: Patients in the NACT group were younger (median age 65 vs. 72 years; p = 0.001) and had fewer comorbidities. NACT was associated with a higher incidence of proximal tumors (54–49.1% vs. 37–25.7%; p = 0.001), diffuse-type tumors (27–45.8% vs. 39–31.7%; p = 0.03), and lymph-node metastases (82–74.1% vs. 84–58%; p = 0.007). No significant differences were observed in median hospital stay (9 (7–16) and 10 (8–22) days for the upfront and NACT groups, respectively; p = 0.26), post-operative mortality (11–7.6% and 5–4.5% for the upfront and NACT groups, respectively; p = 0.32), and major complications (30–20.8% and 23–20.9% for the upfront and NACT groups, respectively; p = 0.99). Among patients receiving NACT, the FLOT regimen was associated with a lower rate of complications (12–16.2% vs. 11–30.5% in the non-FLOT cohort; p = 0.05) and reoperations (4–5.4% vs. 8–22.2% in the non-FLOT group; p = 0.008). Tumor location was identified as an independent predictor of perioperative complications (OR 4.7, 95% C.I.: 1.56–14.18; p = 0.006), while non-FLOT regimens were independently associated with higher reoperation rates (OR 0.22, 95% C.I.: 0.06–0.86; p = 0.003). Five-year OS was comparable between the two groups (44.6% in the NACT group vs. 47.7% in the upfront surgery group; p = 0.96). N+ status (OR 2.5, 95% C.I. 1.42–4.40; p = 0.001) and R+ margins (OR 1.89, 95% C.I. 0.98–3.65; p = 0.006) were negative independent prognostic factors for DFS. Conclusions: Although several selection biases limit the generalizability of our findings, our results suggest that NACT prior to gastrectomy for GC does not increase postoperative morbidity and mortality in appropriately selected patients. However, its use in elderly and polymorbid patients should be carefully considered to determine the safest and most effective therapeutic approach, particularly in selecting the appropriate chemotherapy regimen, to minimize the risk of postoperative complications requiring surgical reintervention.

BACKGROUND Gastrectomy is recognized as a potential cause of exocrine pancreatic insufficiency (EPI). However, limited data are available regarding the incidence and impact of EPI on quality of life (QoL) following gastric surgery. AIM To evaluate incidence and severity of EPI after gastrectomy and its effect on QoL at least one year after surgery. METHODS EPI was assessed using fecal elastase measurement and classified into: (1) No-EPI (fecal elastase > 200 μg/g); (2) Moderate EPI (fecal elastase 100–200 μg/g); and (3) severe EPI (fecal elastase < 100 μg/g). QoL was measured using the Gastrointestinal Quality of Life Index (GIQLI) questionnaire. RESULTS Sixteen out of 44 (36.4%) patients developed EPI post-operatively: 9 (56.2%) patients had moderate EPI while 7 (43.8%) patients had severe EPI. Severe EPI was more frequently observed in younger patients (5/7: 71.4%; P = 0.05), in more advanced disease stages (7/7: 100%; P = 0.05), lymph nodes metastases (7/7: 100%; P = 0.04) and in the mixed histotypes (4/7: 66.7%; P = 0.02) compared to the no-EPI and moderate EPI groups. QoL analysis showed that severe EPI was associated with a significantly lower overall GIQLI score [65 (59–92)] compared to the no-EPI/moderate EPI groups [89 (84–100)] (P = 0.002). Lower scores were particularly evident in the core (P < 0.0001) and disease-specific symptoms domains (P = 0.002) in the severe EPI group compared to the no-EPI/moderate EPI groups. CONCLUSION Gastrectomy is a cause of EPI. Younger patients, aggressive disease and advanced stages are significant risk factors for more severe EPI. Severe EPI worsens QoL, being associated with a higher rate of gastrointestinal symptoms.