Background: Recent evidence suggests that gut microbiome plays a role in the development of pancreatic ductal adenocarcinoma (PDAC) and influences treatment response. However, the association of tumor location and preoperative biliary stenting (PBS) with gut microbial composition and diversity remains poorly understood. Methods: Preoperative stool specimens were prospectively collected from patients with PDAC undergoing surgery between March 2020 and July 2021 at the Department of Surgery, Heidelberg University Hospital, Germany. Whole-genome shotgun metagenomic sequencing was performed. Microbial diversity was assessed using the Shannon index and Bray–Curtis dissimilarity with principal coordinates analysis. Results: A total of 63 preoperative stool samples were analyzed from 40 patients with pancreatic head (63.5%) and 23 with body/tail tumors (36.5%). Baseline characteristics were comparable between groups. Microbial community composition differed significantly between tumor locations (Bray–Curtis, p = 0.005), with enrichment of Ruminococcus bromii in body/tail tumors. Among patients with pancreatic head tumors, PBS was associated with reduced alpha diversity (Shannon index, p = 0.04) and depletion of taxa including Eubacteriales and Clostridiales taxa, and members of the genera Raoultella and Prevotella. PBS was associated with a higher rate of major complications > 3a according to the Clavien–Dindo classification (28.6% vs. 3.8%; p = 0.04). Conclusions: PBS was associated with reduced microbial diversity and distinct taxonomic alterations of the gut microbiome. These findings suggest that biliary stenting is associated with microbiome alterations that may be relevant for perioperative risk stratification and warrant further investigation.

Enhanced recovery after surgery (ERAS) is a widely accepted program aimed at improving short-term outcomes in patients undergoing colorectal surgery. To ac

Introduction: Robotic pancreatic enucleation (rPE) has emerged as a parenchyma-sparing surgical approach for benign or low-grade malignant pancreatic lesions. However, standardized metrics to assess perioperative quality are lacking. This study aimed to propose an rPE-specific textbook outcome (rPE-TO) reflecting an ideal perioperative pathway and to evaluate its applicability in two independent institutional cohorts. Material and methods: Patients undergoing completed rPE at University Hospital Heidelberg, Germany, between April 2023 and March 2025 were analyzed, and the proposed rPE-TO was additionally evaluated in an independent institutional cohort from Johns Hopkins University, Maryland, USA. The rPE-TO comprised six components: no conversion to open surgery, no incomplete resection requiring reoperation, no clinically relevant postoperative pancreatic fistula (POPF), no major complications (Clavien–Dindo < IIIa, with POPF assessed separately), no readmission within 30 days, and no mortality within 90 days. Results: The Heidelberg cohort included 31 patients, of whom 20 (64.5%) achieved rPE-TO. Among the individual components, conversion to open surgery occurred in 4 patients (12.9%), incomplete resection requiring reoperation in 1 (3.2%), POPF in 6 (19.4%), major complications in 2 (6.5%), and 30-day readmission in 2 (6.5%); no 90-day mortality occurred. In the Johns Hopkins cohort ( n = 48), rPE-TO was achieved in 29 patients (60.4%). Despite comparable overall rPE-TO rates, the distribution of individual failure components differed between institutions. In addition, length of hospital stay was shorter among patients achieving rPE-TO in both cohorts. Conclusion: Textbook outcome was achieved in approximately two thirds of patients undergoing rPE in both institutional cohorts. The proposed rPE-TO integrates established perioperative quality measures with procedure-specific outcomes and may provide a composite measure for assessing an ideal perioperative pathway after robotic pancreatic enucleation.