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.

Introduction: Laparoscopic pancreaticoduodenectomy (L-PD) is a safe procedure in high volume centers.¹ Postoperative pancreatic fistula (POPF) is the most feared complication of PD.² Several techniques have been reported to reduce the occurrence of POPF or to mitigate its sequelae. Blumgart pancreaticojejunostomy (PJ) is considered one of the most secure anastomoses.³ Different laparoscopic modified Blumgart (LMB) techniques have been described^4–7: the proper selection of the stitches and their usage remains a critical issue. This video shows an LMB-PJ using a customized suture performed in a 69-year-old man, American Society of Anesthesiologists Status 2, with a distal cholangiocarcinoma. Methods: Five trocars were utilized to perform the L-PD reconstruction.⁸ Six interrupted sutures were used to perform the duct to mucosa anastomosis. Considering the Wirsung diameter (<3 mm) a biodegradable internal stent was placed. An LMB-PJ was performed with four U interrupted sutures. Two drains were placed. Results: The overall operation time was 550 minutes. The LMB PJ time was 70 minutes. Drain amylases at postoperative day (POD) 1 and 3 were 1080 and 955 U/L, respectively. The patient was discharged at POD 9 without drains. To date, LMB PJ has been performed in nine patients. Mean age at surgery was 71.7 years, male/female ratio was 4/5, seven patients (78%) had an FRS class >low, pancreatic stent was placed in five patients (56%); mean postoperative stay was 18 days, severe complications (Clavien–Dindo >2) were present in three patients (33%), two of which had a clinically relevant POPF. There were no mortalities or readmissions. Conclusions: Using a premade customized double armed suture, the LMB anastomosis allows a total invagination of the pancreatic stump edge. The customized double needle suture enables laparoscopic suturing on the jejunal loop, whereas avoiding knotting on the more fragile pancreatic tissue. Acknowledgments: The authors thank Davide Soldini for his valuable contribution to video editing. Patient consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No competing financial interests exist. Runtime of video: 9 mins 59 secs

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.

Background: In Alzheimer’s disease, apathy is a common behavioral sign (AD). The Apathy Evaluation Scale (AES) is a measure that investigates caregivers' (CG‐AES) and patients' (PT‐AES) perceptions of apathy, and the discrepancy in their evaluations is a proxy for patients' illness unawareness. We aimed to determine whether apathy and awareness of apathy predict dementia development and timing in a cohort study of individuals with amnesic mild cognitive impairment (aMCI).Method: We acquired two main indices for analysis from the global AES scores of 110 patients with aMCI and their caregivers: i) ‘Apathy,’ the mean of PT‐AES and CG‐AES, and ii) ‘Discrepancy,’ obtained by subtracting CG‐AES from PT‐AES. Patients were seen every six months for three years, or until they developed dementia. The AES indices and the major demographical/neuropsychological variables were filtered for multicollinearity, and the most robust variables were entered into a logistic regression model and survival analyses (Cox regression, log‐rank test of Kaplan‐Meier curves) to estimate which variables predicted the risk and timing of progression, respectively.Result: 60 patients (54.5%) showed signs of dementia (57 AD) after 6.0‐36.0 months, whereas 28 patients (25.5%) dropped out and 22 patients (20%) were still in an MCI stage. The “Discrepancy” index was a reliable and accurate predictor of the probability of progression (AUC = 0.73) and, after binarization in accordance with a calculated cutoff, of the time to dementia.Conclusion: A structured assessment of apathy, both by the patient and by the caregiver, can reveal important details about the likelihood and timing of the transition from aMCI to dementia. The difference between the two estimations serves as a reliable predictor of illness unawareness by patients.