Pancreatic ductal adenocarcinoma (PDAC) remains one of the most lethal malignancies, with a 5-year overall survival below 12% and high recurrence rates even after R0 resection. Traditionally managed with a “surgery-first” approach, two consistent observations—the near-universal presence of micrometastatic disease at diagnosis and the frequent inability to complete adjuvant therapy—have driven the integration of neoadjuvant therapy (NAT) into clinical practice. NAT offers several theoretical and practical advantages: early systemic control of occult disease, improved delivery and completion of multimodal treatment, biological selection of surgical candidates, and increased R0 resection rates. While in borderline resectable PDAC, randomized trials have consistently demonstrated improved margin-negative resection rates and early survival benefits compared with upfront surgery, in resectable PDAC, evidence is more heterogeneous. Real-world studies corroborate trial findings, reporting higher R0 rates and reduced lymph node positivity without increased perioperative risk, but also highlight substantial heterogeneity in regimens, duration, and radiotherapy use. Limitations to universal NAT adoption include reliance on anatomy-based resectability criteria, absence of validated predictive biomarkers, challenges in response assessment, and concerns over disease progression during preoperative treatment. Future developments will focus on integrating molecular profiling, circulating tumor DNA dynamics, and advanced imaging into patient selection and treatment adaptation, supported by biomarker-enriched and adaptive trial designs. NAT is thus evolving from a selective strategy for borderline disease to an innovative framework to optimize multimodal treatment delivery and refine patient selection in PDAC, with the potential to improve surgical outcomes and inform systemic therapy decisions in both resectable and borderline resectable settings

Background. Postoperative pancreatic fistula (POPF) remains one of the most relevant complications following pancreaticoduodenectomy (PD), significantly impacting short-term outcomes and delaying adjuvant therapies. Current predictive models offer limited accuracy, often failing to incorporate early postoperative data. This retrospective study aimed to develop and validate machine learning (ML) models to predict the absence and severity of POPF using clinical, surgical, and early postoperative variables. Methods. Data from 216 patients undergoing PD were analyzed. A total of twenty-four machine learning (ML) algorithms were systematically evaluated using the Matthews Correlation Coefficient (MCC) and AUC-ROC metrics. Among these, the GradientBoostingClassifier consistently outperformed all other models, demonstrating the best predictive performance, particularly in identifying patients at low risk of postoperative pancreatic fistula (POPF) during the early postoperative period. To enhance transparency and interpretability, a SHAP (SHapley Additive exPlanations) analysis was applied, highlighting the key role of early postoperative biomarkers in the model predictions. Results. The performance of the GradientBoostingClassifier was also directly compared to that of a traditional logistic regression model, confirming the superior predictive performance over conventional approaches. This study demonstrates that ML can effectively stratify POPF risk, potentially supporting early drain removal and optimizing postoperative management. Conclusions. While the model showed promising performance in a single-center cohort, external validation across different surgical settings will be essential to confirm its generalizability and clinical utility. The integration of ML into clinical workflows may represent a step forward in delivering personalized and dynamic care after pancreatic surgery.

Robotic-assisted surgery (RAS) has increasingly gained interest in gastric cancer treatment due to its enhanced precision and vision. Hugo™ RAS is a novel system designed to improve accessibility and reduce costs. However, its use in oncologic upper gastrointestinal procedures is still scarcely documented. We report four consecutive cases of subtotal gastrectomy with D2 lymphadenectomy performed using Hugo™ RAS at a single institution. Patients were selected following multidisciplinary evaluation and underwent full robotic procedures with standardized port placements. Intraoperative parameters, complications, and short-term oncologic outcomes were analyzed. All procedures were completed successfully without conversion or major complications. Median docking and console times were within acceptable limits, though longer than traditional laparoscopy due to system learning curve and intraoperative frozen section use. Lymphadenectomy was adequate in all D2 cases with R0 resection achieved. No blood transfusions were needed. Postoperative complications included delayed gastric emptying and a duodenal stump leak. The system proved safe, and the procedural setup did not require modifications from laparoscopic standards. Subtotal gastrectomy with D2 lymphadenectomy using Hugo™ RAS is feasible and safe. The standardized setup and available instruments support oncologic adequacy without energy devices. Further studies are needed to validate long-term outcomes and assess comparative advantages over conventional approaches.

Background/Objectives: Colorectal cancer (CRC) is one of the most commonly diagnosed malignancies worldwide and a leading cause of cancer-related mortality. Surgical resection remains the cornerstone of curative treatment. Over the past two decades, robotic-assisted surgery has emerged as an evolution of minimally invasive surgery, aiming to overcome several limitations of conventional laparoscopy. This narrative review summarizes the current state of the art of robotic surgery in CRC. Methods: A narrative review of the literature was conducted using PubMed/MEDLINE and Scopus databases, focusing on publications from 2015 to 2026. The review provides an overview of robotic platforms and summarizes the available clinical evidence. Priority was given to randomized controlled trials, meta-analyses, large observational studies, and clinical practice guidelines. The review focuses on major commercially available robotic systems, including the da Vinci^®, Hugo™ RAS, and Versius^® platforms, as well as emerging robotic technologies. Results: Robotic colorectal surgery showed potentially favorable perioperative and oncological outcomes compared with laparoscopy. In rectal cancer, robotic approaches were associated with improved total mesorectal excision quality, lower conversion rates, and improved postoperative functional outcomes. Emerging evidence also suggested potential improvements in disease-free survival and local disease control following robotic rectal surgery. In colon cancer, robotic colectomy were associated with lower conversion rates, reduced blood loss, and faster postoperative recovery, with comparable long-term oncological outcomes. However, robotic procedures showed longer operative times and higher procedural costs. Conclusions: Robotic colorectal surgery appears to be a safe and effective minimally invasive approach, particularly in rectal cancer surgery. The development of new robotic platforms and increasing market competition may improve cost sustainability and expand its future role in colorectal cancer management.

Postoperative pancreatic fistula (POPF) is a major complication after pancreaticoduodenectomy (PD), with significant impact on outcomes. While the absence of pancreatic fibrosis is a known risk factor, its intraoperative assessment is often subjective. Moreover, the potential protective role of chronic inflammation at the pancreatic resection margin (PRM) has not been fully explored. This study aimed to evaluate the histological presence of fibrosis and chronic lymphomononuclear inflammatory infiltrate (CLII) at the PRM as predictors of POPF and clinically relevant POPF (CR-POPF), and to assess their intraoperative feasibility via frozen sections. A retrospective analysis was performed on 141 patients who underwent PD (2014–2022). Intraoperative frozen sections of the PRM were reviewed for fibrosis and CLII using standardized semi-quantitative grading. Univariate and multivariate analyses identified predictors of POPF and CR-POPF. POPF and CR-POPF occurred in 42.5 % and 22.7 % of patients, respectively. Absence of fibrosis and CLII were independently associated with increased risk of POPF (OR 7.51 and 4.30; p < 0.0001) and CR-POPF (OR 4.43 and 3.40; p = 0.0003 and p = 0.0099). Combined absence of both further elevated risk (OR 5.20 for POPF; OR 4.83 for CR-POPF). In multivariate analysis, absence of fibrosis and CLII and main pancreatic duct <3 mm remained independent predictors. The absence of fibrosis and CLII at the PRM strongly predicts POPF and CR-POPF. Their intraoperative evaluation via frozen sections is feasible and may support tailored surgical strategies, especially in minimally invasive PD.