Declan

@hpbsurgeon1 @IHPBA This is an excellent point…. To expand what are the standards that we should be achieving, what numbers are needed to reach those, both centre and surgeon, what is the volume of cases to support a RPD practice assuming not all cases suitable?

History has shown us—repeatedly—that many techniques were once “not cost-effective” until they were. The real takeaway is not whether LPD or RPD is acceptable or not, whether it should exist or not—but where, by whom, and under what conditions they should be performed, while we continue to refine training, selection criteria and systems efficiency. That’s how progress stays both responsibly and progressively.

Ricci et al. used RCT-based modeling to assess minimally invasive pancreaticoduodenectomy. With marginal benefit, much higher costs, laparoscopic and robotic PD were not cost-effective vs open surgery urging caution until stronger evidence emerges 🔗tinyurl.com/4r9hseaf

NACT in resectable pancreatic cancer CISPD-1 phase 3 RCT Sequential neoadjuvant Gem/ nab→ mFOLFIRINOX vs upfront Sx improved 👉EFS (15.3 vs 10.9 mo; HR 0.71, p= 0.0136) 👉OS (35.4 vs 27.2 mo; HR 0.73, p= 0.0477) cell.com/cancer-cell/fu…

The first definitive evidence wherein we might shift the approach to NAT in resectable PDAC? @JorgKleeff

@SyedAAhmad5 @Cancer_Cell Finally!!!! Some evidence supporting neoadjuvant in resectable pdac.

Neoadjuvant nab-paclitaxel plus gemcitabine followed by modified FOLFIRINOX for resectable pancreatic cancer: A randomized phase 3 trial ⁦@Cancer_Cell⁩ cell.com/cancer-cell/fu…

Recurrence after resection of node negative p-net 🦓 How to predict?! 🇺🇸 770 pts 🍒 all node - recurrence 10% 🔮 Recurrence predicted by male sex, size > 3cm, lymphovascular invasion, grading 🤌 The debate about lymphadenectomy in p-net continues! jamanetwork.com/journals/jamas…

In IPMN-derived pancreatic ductal adenocarcinoma, a minimum of 10 lymph nodes should be harvested, and the optimal number to maximize survival is 20 lymph nodes. journals.lww.com/annalsofsurger…

@TheNotoriousHPB Completely agree, teleporting in a delayed PPH is horrendous, unlikely to see bleeding or establish any control. IR first and quickly.

I strongly disagree with re-laparotomy for management of PPH outside of the very early setting, even in unstable patients. In the era of massive transfusion protocols, most pts can be stabilized & managed via angio. Risk doing more harm going back in if you have the resources.

@rajibaji1983 @Gio_Marchegiani @JAMASurgery @MarcBesselink @SyedAAhmad5 @TheNotoriousHPB @ZhiVenFongMD @HalletJulie @Some4SurgeryIT1 @T4UGIS @juliomayol @villesallinen 🤢

@Declanfj @Gio_Marchegiani @JAMASurgery @MarcBesselink @SyedAAhmad5 @TheNotoriousHPB @ZhiVenFongMD @HalletJulie @Some4SurgeryIT1 @T4UGIS @juliomayol @villesallinen 🤣🤣. Do you mean single port laparoscopy….

Save 🐼 laparoscopy! 🤖 Are we allowing robotic surgery to diminish laparoscopic skills that transformed surgical care a generation ago? ⏰ A wake up call for surgical education 💤 jamanetwork.com/journals/jamas…

@rajibaji1983 @TheNotoriousHPB Until AI takes over, and skynet in control.

@TheNotoriousHPB Couldn’t agree more. Standardised protocols have a place, but so does each surgeons brain

The robot is an advanced lap tool and has a role. It cannot be, nor should it be, applied to everything everywhere all at once. Open surgery has a role. I don’t use the CUSA on every liver case. I don’t drain every Whipple patient. “We” should strive to be less hammer-and-nail.

@TheNotoriousHPB @ZhiVenFongMD @HalletJulie @MarcBesselink @DrJashDatta @SyedAAhmad5 @NEJM Until AI predicts and intervenes! thankfully this will hopefully be well beyond my retirement.

@Declanfj @ZhiVenFongMD @HalletJulie @MarcBesselink @DrJashDatta @SyedAAhmad5 @NEJM True…but technology can’t outperform the inherent, non-modifiable risks of patients as well as unexpected events unrelated to technical complications. That’s why we don’t see a signal for MIS Whipple, but see advantages to other MIS cases with no/less complex reconstructions.

Patients were blinded to the surgery until POD 5? How to you even pull that off? Wow. Congrats ⁦@MarcBesselink⁩ Minimally Invasive versus Open Pancreatoduodenectomy for Resectable Neoplasms ⁦@NEJM⁩ evidence.nejm.org/doi/full/10.10…

@TheNotoriousHPB @ZhiVenFongMD @HalletJulie @MarcBesselink @DrJashDatta @SyedAAhmad5 @NEJM Not better than open yet….. if we look at technology one think we know is it’s getting better all the time.

@ZhiVenFongMD @HalletJulie @MarcBesselink @DrJashDatta @SyedAAhmad5 @NEJM 👆 hits the nail on the head. Robotic PD can’t and should not be widely adopted. It’s too complex. But it’s CLEARLY acceptable in the right setting with the right surgeon. It’s not better than open, but can be equivalent. But as I said before, first priority is be a good surgeon.

@ZhiVenFongMD @HalletJulie @MarcBesselink @DrJashDatta @SyedAAhmad5 @NEJM Lots of discussion recently. What centre volume do you need to support RPD program safely? 60 total PD, 100? Robot driving further centralisation?

@HalletJulie @MarcBesselink @DrJashDatta @SyedAAhmad5 @NEJM Agreed but I don’t think RPD should be widely adopted though. Just like how we don’t think everyone should be doing OPDs if hosp is⬇️volume. But these data will be helpful to get the operation covered by insurance. I know a lot of Eastern countries’ payers still don’t cover RPD.

@SyedAAhmad5 @MarcBesselink @DrJashDatta @NEJM I agree it’s too high. When exploring national datasets, eg this US,UK model hospital, Dutch national. Mortality is often 5-10% mark. Differences between high and low volumes exist in all data sets. Should there be minimum volumes? Centre/surgeon.

@MarcBesselink @DrJashDatta @NEJM I think we can all agree, whether it’s in Europe or US or Asia that 5-10% is too high and we need to do better.

@MarcBesselink @DrJashDatta @SyedAAhmad5 @NEJM There’s difference between high-volume center and high-performing center. Poor performing high volume centers exist. Opposite also true. We can debate in good faith. What we can’t debate is that we can’t execute trials in the US anywhere nearly as well as @MarcBesselink and team.

@MarcBesselink @NEJMEvidence @e_mips @DPCG_official @EAHPBA @IHPBA Congratulations!!!!

Is minimally invasive (robot) #Whipple surgery just as safe as open surgery? Today: #DIPLOMA2 RCT in @NEJMEvidence ➡️ evidence.nejm.org/doi/full/10.10… 288 patients, 14 expert centers, 6 countries 🇳🇱🇮🇹🇩🇪🇧🇪🇪🇸🇸🇪): MIS equally safe as open in experienced centers. With faster recovery, fewer wound complications, less pancreatic fistula, and a shorter hospital stay. @nine_degraaf @AnoukEmmen @Abuhilal9Abu @e_mips @EAHPBA

@rajibaji1983 @Gio_Marchegiani @TheLancet @hpb_trials @EvidenceMap @HpbLounge @AISP_Pancreas @PCE_Association @SyedAAhmad5 @HalletJulie @TheNotoriousHPB @lustgartenfdn As do we, it’s our interpretation of current evidence and best standard of care. Though in some cases I do wonder if upfront chemo might be better…..it’s just picking the right ones.

@Declanfj @Gio_Marchegiani @TheLancet @hpb_trials @EvidenceMap @HpbLounge @AISP_Pancreas @PCE_Association @SyedAAhmad5 @HalletJulie @TheNotoriousHPB @lustgartenfdn We offer resectable PDAC upfront surgery @Declanfj

📣 It's out! The PACT-21 CASSANDRA is on @TheLancet 🔵 Preoperative mFOLFIRINOX vs. PAXG for stage I–III PDAC 👑 PAXG prolonged median EFS (16 vs. 10 months) with similar adverse events 🧐 New standard of care !? #fig2" target="_blank" rel="nofollow noopener">thelancet.com/journals/lance…

A new Nature paper just delivered a shock to a long-lived oncology myth. 🔗 nature.com/articles/s4158… For years we’ve been told that radiotherapy—and its cousins like SBRT, TARE, Y-90—might trigger the “abscopal effect,” a systemic immune response that helps control distant disease. This study shows the opposite: radiation induces Amphiregulin (AREG) and can stimulate distant metastasis through myeloid-cell reprogramming. So what does this mean for HPB oncology? 👉 The “abscopal effect” is not a clinical strategy. It’s a story. 👉 Radiation-driven systemic benefit is, at best, unreliable—and at worst, misleading. 👉 Surgery remains the only method of local control with reproducible impact on survival.

@TheNotoriousHPB @Gio_Marchegiani @TheLancet @hpb_trials @EvidenceMap @HpbLounge @AISP_Pancreas @PCE_Association @SyedAAhmad5 @HalletJulie @lustgartenfdn I feel that resectable panc cancer is a system disease so upfront systemic treatment seems sensible…..it’s just so far I don’t think there has been any good randomised data to support it. Some that go against….

@Declanfj @Gio_Marchegiani @TheLancet @hpb_trials @EvidenceMap @HpbLounge @AISP_Pancreas @PCE_Association @SyedAAhmad5 @HalletJulie @lustgartenfdn My bias is still neoadjuvant for resectable, with exceptions. Pending results of Alliance and Preopanc-3, I’ll follow the data. Hopefully clearer than mud 🤞