Backgrounds/Aims: Biliary tract and pancreatic cancers remain leading contributors to cancer-related mortality in Korea, even though their incidence rates are comparatively low. This study evaluates long-term national patterns in these malignancies utilizing population-based data. Methods: Information from the Korea Central Cancer Registry was used to assess 258,854 patients newly diagnosed with gallbladder (n = 52,712), extrahepatic bile duct (n = 76,787), and pancreatic (n = 129,355) cancers between 1999 and 2022. Results: During the period from 1999 to 2022, the crude incidence rates for gallbladder (2.8 to 5.6 per 100,000), extrahepatic bile duct (3.6 to 9.8), and pancreatic cancers (5.5 to 19.1) all showed an upward trend. For pancreatic cancer, the age-standardized incidence rate rose markedly (5.6 to 8.4), whereas it stabilized for extrahepatic bile duct cancer (3.7 to 3.8), and declined for gallbladder cancer (2.9 to 2.2). The distributions of localized and regional disease stages remained largely consistent throughout the study period. There was an increase in the proportion of patients undergoing surgical intervention within the first 4 months post-diagnosis for gallbladder (42.3% to 48.2%) and pancreatic cancer (22.5% to 23.7%), while this proportion slightly declined in extrahepatic bile duct cancer (47.8% to 46.0%). The overall 5-year relative survival rate improved significantly in gallbladder (21.9% to 32.1%) and pancreatic (8.6% to 15.5%) cancers, and showed a modest improvement in extrahepatic bile duct cancer (23.1% to 27.2%). Conclusions: The crude incidence rates for gallbladder, extrahepatic bile duct, and pancreatic cancers have continuously risen in Korea. While survival rates have improved, the persistently high mortality rates highlight the critical need for earlier diagnosis and advancements in therapeutic approaches.

Simple hepatic cysts are now diagnosed in over 8,000 individuals annually in South Korea, largely due to the widespread adoption of medical check-ups and advancements in imaging techniques. However, no appropriate clinical practice guideline has been established to address this condition. While international guidelines have recently been published, differences in clinical and epidemiological contexts have highlighted the need for a tailored guideline to assist domestic clinicians. To address this, the Clinical Practice Guideline Development Committee of Korea Association Hepato-Biliary-Pancreatic Surgery gathered input from surgeons, physicians, radiologists, pathologists, and epidemiology experts to adapt and modify pre-existing international guidelines to better suit domestic realities. This clinical practice guideline aims to provide a clear and appropriate pathway for the management of patients with simple hepatic cysts. It is anticipated that, based on this guideline, clinicians will have a practical framework for diagnosis and treatment. In the near future, it will be necessary to collect high-level evidences to further refine and strengthen recommendations for subsequent guideline updates.

Acute pancreatitis is one of the most common gastrointestinal diseases, with necrotizing pancreatitis affecting 10% to 15% of patients. Over recent years, the management of pancreatic necrosis has evolved significantly, with a growing shift towards minimally invasive approaches. The aim of this study was to evaluate the effectiveness of minimally invasive approach compared to open surgical approach in managing necrotizing acute pancreatitis. A systematic review and meta-analysis were conducted, including 22 studies. Both fixed-effect and random-effect models were applied to analyze nine outcomes evaluated. Homogeneity among studies was assessed using χ² tests, I² statistics, and p-values. The risk of postoperative mortality, intra-abdominal bleeding, pancreatic and enteric fistulas, perforation, new-onset diabetes, and postoperative sepsis was significantly lower in the minimally invasive approach group than in the open surgical approach group. A minimally invasive approach to necrotizing acute pancreatitis might be associated with a lower risk of complications compared to an open surgical approach. However, most of the included studies were observational studies. Additional randomized trials are needed to further confirm these findings.

Total pancreatectomy with islet autotransplantation (TPIAT) is a specialized treatment for chronic pancreatitis (CP) patients experiencing intractable pain, aiming to preserve endocrine function and enhance quality of life. This narrative review explores the evolution of islet isolation techniques and their impact on yields and clinical outcomes in TPIAT. PubMed and Google Scholar were searched utilizing the keywords: total pancreatectomy, islet autotransplantation, islet transplantation, TPIAT, islet yields, islet isolation. This review underscores significant advances in islet isolation, from initial collagenase-based methods to the automated Ricordi technique and the enzyme Liberase, which have significantly improved islet yield and viability. Factors such as pancreatic fibrosis, preoperative nutritional status, and ischemia times are critical determinants of outcomes. Higher islet yields (> 5,000 islets/kg) correlate with substantially better insulin independence (20%-40% at 1 year), while pain relief (80%-90%) and quality of life improvements (60%-70%) are consistently observed. Variability in yields due to disease severity and levels of technical expertise continues to pose challenges. TPIAT has evolved into a widely accepted treatment option for CP, with advanced islet isolation techniques contributing to enhanced clinical success. Despite these advancements, variability in islet yields and outcomes highlights the need for standardized protocols and optimized preservation techniques. Future research should aim to address challenges associated with fibrosis and improve long-term graft function, thereby maximizing TPIAT's therapeutic potential.

Backgrounds/Aims: This study evaluates whether positive resection margins after colorectal liver metastasis (CRLM) surgery are linked to tumor recurrence and impact long-term survival. Methods: The oncological outcomes of patients undergoing curative resection for CRLM at a single institution were analyzed concerning clinicopathological factors using both univariate and multivariate statistical methods. Results: Among 138 patients who underwent liver resection for CRLM, hepatic tumor recurrence was noted in 70 patients (50.7%), with no significant difference between those with R0 and R1 resections (p = 0.33). Positive resection margins were associated with tumor proximity to major liver vascular structures, while negative margins corresponded more frequently with T4 stage colorectal cancer. Multivariate analysis indicated that R1 margins in CRLM resections do not affect overall or disease-free survival. Nonetheless, the proximity of tumors to major liver vascular structures and R1 margins from initial colorectal cancer resections were significant independent predictors of poorer survival outcomes. Conclusions: With the advent of modern perioperative systemic therapies, both hepatic recurrence and survival outcomes following hepatectomy for colorectal liver metastases seem unaffected by the presence of R1 resection margins.

Backgrounds/Aims: Post-hepatectomy liver failure (PHLF) is a significant complication with an incidence rate between 8% and 12%. Machine learning (ML) can analyze large datasets to uncover patterns not apparent through traditional methods, enhancing PHLF prediction and potentially mitigate complications. Methods: Using the National Surgical Quality Improvement Program (NSQIP) database, patients who underwent hepatectomy were randomized into training and testing sets. ML algorithms, including LightGBM, Random Forest, XGBoost, and Deep Neural Networks, were evaluated against logistic regression. Performance metrics included receiver operating characteristic area under the curve (ROC AUC) and Brier score loss. Shapley Additive exPlanations was used to identify individual variable relevance. Results: 28,192 patients from 2013 to 2021 who underwent hepatectomy were included; PHLF occurred in 1,305 patients (4.6%). Preoperative and intraoperative factors most contributed to PHLF. Preoperative factors were international normalized ratio > 1.0, sodium < 139 mEq/L, albumin < 3.9 g/dL, American Society of Anesthesiologists score > 2, total bilirubin > 0.65 mg/dL. Intraoperative risks include transfusion requirements, trisectionectomy, operative time > 266.5 minutes, open surgical approach. The LightGBM model performed best with an ROC AUC of 0.8349 and a Brier Score loss of 0.0834. Conclusions: While topical, the role of ML models in surgical risk stratification is evolving. This paper shows the potential of ML algorithms in identifying important subclinical changes that could affect surgical outcomes. Thresholds explored should not be taken as clinical cutoffs but as a proof of concept of how ML models could provide clinicians more information. Such integration could lead to improved clinical outcomes and efficiency in patient care.

Backgrounds/Aims: Surgical data science (SDS) is an emerging discipline that aims to enhance the quality of interventional healthcare by capturing and analyzing intraoperative data. Our study focused on identifying human errors (HEs) and adverse events (AEs) during elective liver surgery using an SDS-based approach. Methods: Intraoperative data from 15 patients undergoing elective open liver resection were collected using an operating room data system (audio, room, and operative field videos) over a 6-month period in a tertiary hepatobiliary surgical center. Two independent researchers analyzed the data to identify HEs and AEs according to two distinct classifications. Results: A total of 154 HEs (median number per intervention: 7) and 42 AEs (33 minor, 9 major) were identified. All except one major AE were associated with HEs, while 15 minor AEs had no identifiable underlying HEs. The type of HEs significantly varied depending on the presence or absence of AEs. The majority of HEs (n = 128, 83.1%), which did not result in any AEs, primarily involved lapses in attention, whereas approximately half of the AEs were linked to failures in recognition. Conclusions: This preliminary study indicates that failures in recognition were frequently associated with major AEs during elective liver resection, as per the SDS approach. Larger multicenter studies are necessary to confirm these findings and develop preventive strategies.

Backgrounds/Aims: Laparoscopic cholecystectomy (LC) is the standard therapy for acute calculous cholecystitis (ACC). However, high-risk patients often require percutaneous gallbladder drainage (PGBD) as a bridge to surgery. The optimal interval between PGBD and LC remains uncertain. Methods: We retrospectively reviewed 177 patients who underwent LC after PGBD for ACC at Nhan dan Gia Dinh Hospital (2018-2024). Patients were stratified by drainage-to-surgery interval: Q1, ≤ 9 days; Q2, 10-17 days; Q3, 18-32 days; Q4, ≥ 32 days. Primary outcomes were operative time, conversion, intraoperative bleeding, postoperative stay, and Clavien-Dindo complications. Multivariable logistic regression was performed after adjusting for age, Charlson Comorbidity Index (CCI), TG18 severity, sex, prior endoscopic retrograde cholangiopancreatography, and Concurrent PGBD and LC during the same admission. Results: Median operative time, conversion rate, and postoperative stay were similar across intervals. Crude bleeding differed significantly (p = 0.019), being the highest in Q4 (68.2%) and the lowest in Q2 (36.4%). Q3 showed the shortest operative time (median: 90 min) and the lowest complication rate (11.4%). In adjusted analysis, only CCI independently predicted bleeding (adjusted odds ratio: 1.42; 95% confidence interval: 1.02-2.03), while timing lost its statistical significance. Conclusions: Scheduling LC 18-32 days after PGBD offers the most balanced surgical profile, whereas delaying beyond 32 days increases bleeding without added benefit. Comorbidity burden rather than calendar interval per se appears to increase bleeding risk. Prospective studies are warranted to confirm the intermediate 2- to 4-week window.

Backgrounds/Aims: Groove pancreatitis (GP) is a seldom encountered form of chronic pancreatitis characterized by inflammation of the pancreatoduodenal groove. Our study presents our experience with pancreatoduodenectomy (PD) for GP at a tertiary referral center. Methods: We conducted a retrospective review of patients who underwent PD for a preoperative diagnosis of GP at a tertiary referral center from 2010 to 2024. The primary outcomes were long-term pain relief and risks of recurrent pancreatitis, exocrine, and endocrine insufficiency. Secondary outcomes included perioperative complications. Results: During the study period, 19 patients underwent PD for GP. The median age was 45.5 years, and all patients were male. Eighty percent of the patients had a history of alcohol consumption and smoking. The median duration of symptoms was 24 months, with pain being the most prevalent symptom (94.73%). The overall complication rate (Clavien-Dindo grades 1-5) was 52.63% (10/19), and the major complication rate (Clavien-Dindo grades 3-5) was 21.05%. The median follow-up period was 67.25 months. Complete pain relief was achieved in 73.33% (11/15) of the patients, with the remaining 26.66% (4/15) experiencing partial resolution of pain. Among these, all had recurrent pancreatitis in the remnant pancreas, with ongoing alcohol consumption (n = 3) or smoking (n = 4). New-onset diabetes mellitus and steatorrhea were observed in 42.85% (6/14) and 21.42% (3/14) of patients, respectively. Furthermore, 71.42% (10/14) reported weight gain, with a median increase of 13.5 kg (range 5.00-22.75 kg). Conclusions: PD for GP offers substantial long-term pain relief with acceptable levels of perioperative morbidity and mortality.

Backgrounds/Aims: Postoperative pain recurrence is a challenging issue in chronic pancreatitis (CP). This study explores the incidence and factors contributing to recurrent pain after surgery. Methods: An ambispective observational study evaluated patients with painful CP undergoing surgery from 2011 to 2022. The intensity frequency consequence (IFC) pain score and the painDETECT questionnaire were utilized to assess pain before and after surgery. Patients were categorized into 2 groups based on their IFC pain scores: a pain group and a pain-free group. Clinical, radiological, surgical, and post-surgical parameters were compared between these groups using the student t-test and logistic regression for continuous and categorical variables, respectively. A p-value of < 0.05 was deemed significant. Multivariate analysis was conducted. Results: A total of 125 patients were enrolled (pain group, 71 [56.8%]; pain-free group, 54 [43.2%]). In the pain group, 65 experienced mild and 6 experienced moderate pain. The average post-surgery pain score was significantly lower than the pre-surgery score (13.7 vs 2.5, p < 0.001). Multivariate analyses revealed that intravenous (IV) analgesics and preoperative endoscopic interventions were independent predictors of recurrent pain. Conclusions: The incidence of recurrent pain in CP patients post-surgery was 56.8%, with a significant reduction in pain intensity postoperatively. Patients who required preoperative IV analgesics and underwent endoscopic interventions demonstrated a higher risk of recurrent pain. Neuropathic pain was not identified as a cause of pain recurrence in this study.

Backgrounds/Aims: Portal annular pancreas (PAP) is an anomaly where pancreatic tissue surrounds the portal vein (PV). We present a case series from our institution and a systematic review of PAP patients who underwent pancreatoduodenectomy (PD). Methods: We conducted a retrospective review of patient records from a tertiary referral center, from January 2014 to June 2024, who underwent PD to identify those with PAP. Additionally, a literature search was performed and articles discussing PAP patients who underwent PD were included. Results: The incidence of PAP was 0.4% (7 out of 1,750 PD cases). Of these, three (42.85%) patients developed clinically relevant postoperative pancreatic fistula (CR-POPF). Following the literature review, 34 articles with 57 patients (including our study) were considered. Reconstruction of the dominant stump, which included the main pancreatic duct, was performed using pancreatojejunostomy in 88.88% of cases and pancreatogastrostomy in 11.11% of cases. The non-dominant stump was managed with en-bloc extended resection (ER) of PAP, leftward of the PV, offering a single-cut surface for pancreatojejunostomy (41.51%), by stapling (26.41%) or suturing the stump (16.98%), stump-pancreatogastrostomy (5.66%), and electrocautery (5.66%). CR-POPF rates for ER, suturing and stapling were 22.72%, 37.5%, and 53.85%, respectively (p = 0.12). Conclusions: Preoperative recognition of PAP is crucial to customize surgical procedures to effectively manage the non-dominant stump.

Backgrounds/Aims: Pancreaticoduodenectomy (PD) is the standard treatment for resectable tumors of the pancreatic head, ampulla, distal bile duct, and duodenum. Despite advances, delayed gastric emptying (DGE) remains a common complication. Feeding jejunostomy (FJ) is often used during PD, though its necessity and association with increased morbidity, particularly DGE, remain controversial. This study aimed to evaluate early postoperative outcomes in PD patients with or without FJ, focusing on DGE and related complications. Methods: This prospective observational study was conducted from August 2022 to April 2024 and included 56 patients (28 with FJ, 28 without). Primary outcomes were DGE, postoperative pancreatic fistula (POPF), and hospital stay. Secondary outcomes included FJ-related complications, surgical site infections, and time to tolerate solid food. Statistical analysis was performed using SPSS v28. Results: DGE was significantly more frequent in the FJ group (78.6% vs. 39.3%, p = 0.006). Clinically relevant DGE (grades B/C) was also higher with FJ (60.7% vs. 21.4%, p = 0.008). FJ-related complications, including intestinal obstruction requiring reoperation, occurred in 10.7% of patients. Time to tolerate solid food and hospital stay were longer in the FJ group. Multivariate analysis identified FJ use and perioperative blood transfusion as independent risk factors for DGE. Conclusions: Routine FJ placement in PD is associated with increased DGE and tube-related complications. A selective approach to FJ may improve postoperative outcomes. Larger multicenter randomized trials are needed to validate these findings and develop clear guidelines for FJ use in PD.

Backgrounds/Aims: Arterial resection in pancreatic cancer remains controversial. This study evaluates outcomes of pancreatic resection with arterial involvement following neoadjuvant chemotherapy. Methods: Retrospective analysis of 100 pancreatic adenocarcinoma patients undergoing resection after neoadjuvant FOLFIRINOX (2010-2024): 26 with arterial resection (ArP), 39 with portal-venous resection (PoP), and 35 without vascular involvement (NoP). Primary outcomes included perioperative morbidity, mortality, and survival. Results: ArP patients had significantly more stage III disease (73.1% vs 58.9% vs 28.6%, p < 0.001) but achieved acceptable R0 resection rates (76.9% vs 84.6% vs 91.4%, p = 0.04). ArP procedures required longer operative time (386 ± 71 minutes), greater blood loss (1,100 ± 560 mL), and more transfusions (57.7%; all p < 0.001). Major complications (Clavien-Dindo ≥ III) were higher in ArP (26.9% vs 21.6% vs 8.6%, p = 0.03), with extended ICU stays (3.5 ± 1.5 vs 2.0 ± 1.0 vs 1.0 ± 0.5 days). Ninety-day mortality was 0% (ArP), 2.5% (PoP), and 5.7% (NoP) (p = 0.78). Despite shorter disease-free survival in ArP (7.4 vs 9.7 vs 13.2 months, p = 0.01), median overall survival was comparable (ArP: 19.1, PoP: 18.3, NoP: 22.7 months; p = 0.0652) Conclusions: Arterial resection following neoadjuvant therapy in selected pancreatic cancer patients demonstrates acceptable perioperative risk and achieves survival outcomes comparable to less advanced cases. This approach is justified in experienced high-volume centers for appropriately selected patients with favorable response to neoadjuvant therapy, offering potential cure in rare circumstances.

Backgrounds/Aims: This study investigated perioperative patterns of red blood cell (RBC) transfusion and related determinants in pancreatic cancer surgery using a nationwide Korean database. Methods: We assessed data from the National Health Insurance Service (NHIS) from 2012 to 2020, including newly diagnosed pancreatic cancer patients aged ≥ 20 years who underwent pancreatic surgery within one-year of their diagnosis. Perioperative RBC transfusion was defined as receiving ≥ 1 unit of allogenic RBCs from one week before surgery through hospital discharge. Results: Of the 10,473 patients, 18% underwent perioperative RBC transfusions. The transfusion rate declined from 20.1% in 2012 to 12.7% in 2015, followed by an increase to 19.9% in 2020. In a multivariate analysis, each 10-year increase in age (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.24-1.37), female sex (OR, 1.16; 95% CI, 1.05-1.29), and being in the lowest-income quartile compared to the highest (OR, 1.29; 95% CI, 1.11-1.49) were associated with an increased likelihood of requiring RBC transfusions. A higher Charlson comorbidity index was independently connected to a greater risk as well. Compared with pancreaticoduodenectomy, total pancreatectomy had higher odds (OR, 1.91; 95% CI, 1.56-2.35), whereas distal pancreatectomy had lower odds. Furthermore, general hospitals, compared with tertiary hospitals, were associated with higher transfusion probability (OR, 1.38; 95% CI, 1.22-1.56). Conclusions: Given rising RBC transfusion rates among low-income patients and limited NHIS coverage for new transfusion-sparing methods, Korea should prioritize broader adoption of multidisciplinary blood management over continued reliance on transfusion.

Backgrounds/Aims: Diabetes is a recognized risk factor for pancreatic cancer; however, precise molecular mechanisms remain unclear. This study aimed to assess the influence of inflammation on the progression of pancreatic cancer in a diabetic murine model utilizing circulating tumor cells (CTC). Methods: Fifty mice were randomly allocated into five groups. The P group were injected Panc02 cells only. In the streptozotocin (STZ), STZ/P, and P/STZ groups, mice were administered intraperitoneal STZ solution (50 mg/kg) alone, prior to Panc02 cell injection, and following Panc02 cell injection, respectively. Tumor development was assessed by gross inspection. Immunohistochemistry was performed to evaluate inflammatory cytokine expression, and CTCs were detected using quantum dot-conjugated aptamers. Results: All mice exposed to STZ developed marked hyperglycemia. Tumor volume to body weight ratio was significantly higher in both P/STZ and STZ/P groups (p < 0.001). Liver metastasis rate was highest in the P/STZ group (p = 0.05). Malondialdehyde (p < 0.001), interleukin-1β (p < 0.05), tumor necrosis factor-α (p < 0.001), and interleukin-6 (p < 0.05) levels were significantly elevated in the STZ/P group. Expression of Signal Transducer and Activator of Transcription 3 and Snail1 was increased in both STZ/P and P/STZ groups. In addition, seven mice in the STZ/P group (70%) and nine mice in the P/STZ group (90%) exhibited larger CTC-like cells (p < 0.001). Conclusions: In STZ-induced murine models, both hyperglycemia and elevated inflammatory markers were observed. Within this diabetes-associated inflammatory microenvironment, pancreatic cancer cells demonstrated increased proliferation and metastasis, as verified by aptasensor-based CTC detection.

We herein present a novel combined posterior and left-sided superior mesenteric artery (SMA) first approach to facilitate the TRIANGLE operation for pancreatoduodenectomy (PD) or total pancreatectomy (TP) in pancreatic cancer. Patients who were diagnosed with resectable pancreatic ductal adenocarcinoma who underwent PD or TP using the combined posterior and left-sided SMA-first approach to the TRIANGLE operation between June 2021 and June 2024 were included in this study. General characteristics, technical details including operative techniques, short-term outcomes, and pathological results were analyzed retrospectively and compared with those from historic cohorts undergoing single SMA-first approach resections. Overall, 126 patients were analyzed (dual-approach PD-TP, n = 33; single-approach PD-TP, n = 93). The dual-approach resection yielded more lymph nodes than the single-approach (36.17 vs 26.53; p < 0.001). Additionally, the rate of tumor-positive resection margins, R1 (direct), was decreased. The duration of the operation was significantly longer, and blood loss was higher with the dual approach. There was no significant difference in postoperative mortality and complications between the two approaches. Utilizing the combined posterior and left-sided first approach to SMA in PD or TP with the TRIANGLE operation proved safe and effective for achieving R0 resection with favorable short-term outcomes in borderline resectable and locally advanced pancreatic cancer.

Non-cirrhotic portal fibrosis (NCPF), a leading cause of non-cirrhotic portal hypertension (NCPH), commonly presents with splenomegaly, esophageal varices, and preserved liver function. While minimally invasive splenectomy (MIS) offers advantages over open splenectomy, concerns persist due to the risks associated with portal hypertension. This study evaluates the feasibility, safety, and long-term outcomes of MIS in non-bleeder NCPF patients, highlighting perioperative challenges and techniques. Thirteen consecutive non-bleeder NCPF patients undergoing MIS between November 2017 and December 2023 were analyzed. Procedures included eight laparoscopic and four robotic splenectomies, with one conversion to open surgery. Additionally, two patients underwent laparoscopic and one robotic gastric devascularization. Perioperative parameters such as operative time, blood loss, hospital stay, and complications were recorded. The median operative time was 240 minutes, and median blood loss was 150 mL. One patient required transfusion, and one developed splanchnic venous thrombosis, managed conservatively. Median hospital stay was three days, with no 90-day mortality. Follow-up assessments included clinical evaluation, blood tests, Doppler ultrasound of the splenoportal axis, and upper gastrointestinal endoscopy. At a median follow-up of 16 months (interquartile range 12-43), significant improvements were observed in hemoglobin, leukocyte, and platelet counts (p < 0.01). Esophageal variceal grades decreased from 2 to 1, while portal vein peak systolic velocity improved from 18 to 27.7 cm/sec (p < 0.01), indicating reduced portal hypertension. No postoperative infections or variceal bleeding recurrences were noted. MIS is a safe and effective treatment option for non-bleeder NCPF with favorable long-term outcomes when performed by skilled surgeons.

Although half of the patients with pancreatic ductal adenocarcinoma (PDAC) are diagnosed at an advanced stage, surgical interventions needed at this stage are currently limited. Carbon-ion radiotherapy (CIRT) has emerged as a promising treatment modality for PDAC owing to its superior physical and radiobiological properties. However, a major challenge in this treatment is the proximity of the pancreas to radiosensitive organs including the stomach and duodenum, which limits dose escalation and increases the risk of severe complications, including ulceration and perforation. Herein, we report our experience with laparoscopic omentopexy as a spacer technique before CIRT in patients with locally advanced PDAC. A 55-year-old female with locally advanced PDAC, secondary to unreconstructible superior mesenteric vein involvement, who had planned to undergo CIRT. After 28 cycles of modified FOLFIRINOX, the tumor size demonstrated slight shrinkage. However, the tumor abutted the posterior wall of the stomach, raising concerns about ensuring a sufficient safety margin while delivering a curative dose of CIRT. Therefore, laparoscopic omentopexy was performed for spacer implantation between the pancreas and stomach. The patient was discharged on the postoperative day 2 without any complications. One month after the omentopexy, the patient completed all 12 fractions of the CIRT with no acute complications, except for grade 1 fatigue. After completing CIRT, the patient underwent regular follow-up evaluations. Laparoscopic omentopexy before CIRT in patients with locally advanced PDAC could enhance therapeutic efficacy.