Value of a nomogram model in early recurrence of pancreatic ductal adenocarcinoma after laparoscopic pancreaticoduodenectomy / 临床肝胆病杂志

ObjectiveTo investigate the risk factors for early tumor recurrence after laparoscopic pancreaticoduodenectomy （LPD） in patients with pancreatic ductal adenocarcinoma （PDAC）， and to establish a predictive model. MethodsA retrospective analysis was performed for the clinical data of 240 PDAC patients who underwent LPD in The First Hospital of Jilin University from April 2016 to July 2022， with early postoperative tumor recurrence （time to recurrence ≤12 months） as the study outcome. The patients were randomly divided into training group with 168 patients and validation group with 72 patients at a ratio of 7∶3. In the training group， there were 70 patients （41.67%） with early postoperative recurrence and 98 （58.33%） without early recurrence， and in the validation group， there were 32 （44.44%） with early postoperative recurrence and 40 （55.56%） without early recurrence. The chi-square test or the Fisher’s exact test was used for comparison of categorical data between groups； a logistic regression analysis was used to investigate the risk factors for early postoperative recurrence； the receiver operating characteristic （ROC） curve and the area under the ROC curve （AUC） were used to evaluate the discriminatory ability of the model， with AUC>0.75 indicating that the model had adequate discriminatory ability. The Bootstrap resampling method was used for validation after 1 000 times of random sampling， and the model was validated again in the validation group. The calibration curve and the Hosmer-Lemeshow goodness-of-fit test were used to evaluate the degree of calibration， and the decision curve analysis was used to evaluate clinical practicability. ResultsThe univariate and multivariate analyses showed that preoperative CA19-9 level≥37 U/mL （odds ratio ［OR］=6.265， 95% confidence interval ［CI］： 1.938‍ ‍—‍ ‍20.249， P<0.05）， maximum tumor diameter >3 cm （OR=10.878， 95%CI： 4.090‍ ‍—‍ ‍28.932， P<0.05）， poor tumor differentiation （OR=3.679， 95%CI： 1.435‍ ‍—‍ ‍9.433， P<0.05）， lymph node metastasis （OR=0.209， 95%CI： 0.080‍ ‍—‍ ‍0.551， P<0.05）， and absence of adjuvant chemotherapy after surgery （OR=0.167， 95%CI： 0.058‍ ‍—‍ ‍0.480， P<0.05）. A nomogram model was constructed based on these factors； the ROC curve analysis showed that the model had an AUC of 0.895 （95%CI： 0.846‍ ‍—‍ ‍0.943， P<0.001）， and the calibration curve and the Hosmer-Lemeshow test showed that the model had a good degree of calibration （P=0.173）. The decision curve analysis showed that the nomogram had a good clinical application value. ConclusionPreoperative CA19-9 level ≥37 U/mL， maximum tumor diameter >3 cm， poor tumor differentiation， lymph node metastasis， and absence of adjuvant chemotherapy after surgery are independent risk factors for the early recurrence of PDAC after LPD， and the nomogram model established based on these factors can effectively predict early postoperative recurrence.

Efficacy and safety of omental wrapping technique for pancreaticojejunal anastomosis in preventing complications after pancreaticoduodenectomy： A Meta-analysis / 临床肝胆病杂志

ObjectiveTo systematically evaluate the efficacy and safety of omental wrapping technique for pancreaticojejunal anastomosis in preventing complications after pancreaticoduodenectomy. MethodsThis study was conducted according to the PRISMA guideline. English and Chinese databases including CNKI， Wanfang Data， VIP， CBM， the Cochrane Library， PubMed， Embase， and Web of Science were searched for clinical studies on omental wrapping technique for pancreaticojejunal anastomosis in preventing complications after pancreaticoduodenectomy published up to November 2022， and Stata 16 and Review Manager 5.4 were used to perform the meta-analysis. ResultsA total of 15 studies with 1 830 patients were included in this study. The meta-analysis showed that the omental wrapping group had a significantly lower overall incidence rate of postoperative pancreatic fistula （POPF） than the non-omental wrapping group （odds ratio ［OR］=0.30， 95% confidence interval ［CI］： 0.22‍ ‍—‍ ‍0.41， P<0.001）， and the subgroup analysis showed that the omental wrapping group had a significantly lower incidence rate of grade B/C POPF than the non-omental wrapping group （OR=0.29， 95%CI： 0.21‍ ‍—‍ ‍0.39， P<0.001）. Compared with the non-omental wrapping group， the omental wrapping group had significantly lower incidence rates of postoperative bile leakage （OR=0.30， 95%CI： 0.16‍ ‍—‍ ‍0.56， P<0.001）， postoperative hemorrhage （OR=0.35， 95%CI： 0.24‍ ‍—‍ ‍0.53， P<0.001）， delayed gastric emptying （OR=0.45， 95%CI： 0.31‍ ‍—‍ ‍0.64， P<0.001）， abdominal infection （OR=0.55， 95%CI： 0.40‍ ‍—‍ ‍0.75， P<0.001）， reoperation （OR=0.31， 95%CI： 0.18‍ ‍—‍ ‍0.54， P<0.001）， and death within 30 days after surgery （OR=0.42， 95%CI： 0.22‍ ‍—‍ ‍0.80， P=0.009）， a significantly earlier time to diet （mean difference ［MD］=-0.98， 95%CI： -1.84 to -0.11， P=0.03）， and a significantly shorter length of postoperative hospital stay （MD=-2.44， 95%CI： -4.10 to -0.77， P=0.004）. There were no significant differences between the two groups in the time of operation （MD=-13.68， 95%CI： -28.31 to -0.95， P=0.07） and intraoperative blood loss （MD=-17.26， 95%CI： -57.55 to -23.03， P=0.40）. ConclusionOmental wrapping can reduce the incidence rates of postoperative complications such as pancreatic fistula， bile leakage， postoperative hemorrhage， abdominal infection， and delayed gastric emptying， improve the prognosis of patients， and shorten the length of hospital stay， without increasing surgical difficulty or time of operation.

Complicaciones de cirugía de Whipple en un paciente pediátrico con tumor pseudopapilar de páncreas / Complications of Whipple procedure in a pediatric patient with pseudopapillary tumor of the pancreas

Las neoplasias de páncreas son una entidad poco frecuente en pediatría; el tumor pseudopapilar de páncreas (TSP) es el más comúnmente diagnosticado. Habitualmente, se localizan en la cabeza del páncreas. La cirugía de Whipple o pancreatoduodenectomía es la técnica elegida para el tratamiento de los tumores benignos o malignos de páncreas. Si bien la mortalidad conocida ha descendido en los últimos años, debido a la mayor experiencia de los cirujanos y al mejor cuidado pre- y posoperatorio, la morbilidad se ha mantenido elevada secundaria a las complicaciones asociadas. Dentro de estas se destacan retardo en el vaciamiento gástrico, colecciones intraabdominales, fístula pancreática, reestenosis del sitio quirúrgico y hemorragia pospancreatectomía. Se presenta el caso clínico de una niña de 13 años con diagnóstico de TSP que recibió tratamiento quirúrgico efectivo desde el punto de vista oncológico, pero que requirió una internación prolongada secundaria a las complicaciones quirúrgicas.

Pancreatic neoplasms are rare in pediatrics; the pseudopapillary tumor (PPT) of the pancreas is the most common. PPTs of the pancreas are usually located in the head of the pancreas. A pancreaticoduodenectomy or Whipple procedure is the technique of choice for the treatment of benign or malignant pancreatic tumors. Although mortality for this cause has decreased in recent years, due to the greater experience of surgeons and improved pre- and postoperative care, morbidity has remained high secondary to associated complications. These include delayed gastric emptying, intra-abdominal collections, pancreatic fistula, surgical site restenosis, and post-pancreatectomy hemorrhage. Here we describe the clinical case of a 13-year-old girl diagnosed with PPT of the pancreas who underwent an effective surgery in terms of cancer treatment, but who required a prolonged hospitalization secondary to surgical complications.

Pancreatoduodenectomía laparoscópica híbrida: resultado en paciente obeso con adenocarcinoma duodenal

La cirugía pancreática mínimamente invasiva sigue ampliando sus indicaciones de manera lenta pero constante. Su aplicación en pacientes obesos y/o con neoplasias periampulares es controversial por la elevada tasa de complicaciones reportada en esta población. Presentamos un paciente de sexo masculino de 62 años, obeso (IMC 35,4 Kg/m2), hipertenso y diabético que desarrolla anemia severa (Hb = 4,9 g/dl) por adenocarcinoma de segunda porción duodenal. El estadiaje por imágenes verifica enfermedad localizada. El paciente fue sometido a pancreatoduodenectomia híbrida (resección laparoscópica/reconstrucción abierta por minilaparotomía). Se describe técnica operatoria y evolución postoperatoria. El paciente cursó sin complicaciones mayores (pancreatitis aguda moderada), el tiempo operatorio fue 540 minutos, el volumen de sangrado 400 ml, requirió la transfusión de 1 unidad de paquete globular y estancia de 8 días. No tuvo intercurrencias durante 90 días después de la cirugía. Se concluye que la pancreatoduodenectomía híbrida es una alternativa factible y segura en pacientes obesos con adenocarcinoma duodenal, ofrece ventajas en la reducción del trauma quirúrgico.

Minimally invasive pancreatic surgery has expanded slowly but steadily. The application of this approach in obese patients and/or with periampullary neoplasms is still controversial because of the high complication rate in this group of patients. We present the case of a 62-year-old male, obese (BMI 35.4 Kg/m2), hypertensive and diabetic, who developed severe anemia (Hb 4.9 g/dl) due to duodenal adenocarcinoma. Imaging staging verified localized disease. The patient underwent Hybrid Pancreatoduodenectomy (laparoscopic resection/open minilaparotomy reconstruction). The operative technique and postoperative course are described. The patient had no major complications (moderate acute pancreatitis), the operative time was 540 minutes, the bleeding volume was 400 ml, he required transfusion of 1 unit of globular package and a stay of 8 days. He had no intercurrences during 90 days after surgery. It is concluded that hybrid pancreatoduodenectomy is a feasible and safe alternative in obese patients with duodenal adenocarcinoma, offering advantages in reducing surgical trauma.

Octreotide and postoperative pancreatic fistula after pancreaticoduodenectomy: What we know so far? A narrative review

Postoperative pancreatic fistula (POPF) is the most feared complication following pancreatic resection. Octreotide, a synthetic somatostatin analog, has been widely used by pancreatic surgeons worldwide after pancreatic resections, often as per surgeon抯 discretion, to prevent POPF especially in cases at high risk of developing POPF. We herein analyze the data available till date of the subject. A PubMed search with keywords 搒omatostatin OR octreotide OR somatostatin analogues AND postoperative pancreatic fistula� was made. Further filters were applied in the search 揅linical Trial, Meta?Analysis, Randomized Controlled Trial, Systematic Review, from 1990 � 2021,� and the 68 results thus obtained were analyzed and included in this narrative review. There is considerable heterogeneity among the studies assessing the role of octreotide in the prevention of POPF making data comparison difficult, and hence results remain inconclusive. Most of the earlier studies used different definitions of POPF and other complications; included patients with varied pancreatic pathologies such as cancer, chronic pancreatitis, and benign lesions; surgical techniques such as pancreaticoduodenectomy, distal pancreatectomy, and other procedures; use of somatostatin and its analogs such as octreotide, lanreotide, pasireotide, and vapreotide; varied surgeon and institutional volume; and so on. Besides, pancreatic surgery is per se a complex surgical procedure and has its own inherent biases related to patient and the pancreas itself affecting the overall outcome. Data indicate favorable role of newer somatostatin analogs, and further studies are urgently needed. The question about the efficacy of prophylactic octreotide to reduce POPF after pancreaticoduodenectomy remains open to debate

Paraganglioma gangliocítico metastásico: una rara entidad histológica diagnosticada tras una duodenopancreatectomía / Metastatic gangliocytic paraganglioma: a rare histological entity diagnosed after duodenopancreatectomy

Introducción. El paraganglioma gangliocítico es una entidad histológica infrecuente, siendo el duodeno su principal localización extra ganglionar. Caso clínico. Se trata de un varón de 54 años que consulta por dolor abdominal y hemorragia digestiva alta. Se diagnosticó una lesión sospechosa de ampuloma por lo que se realizó una duodenopancreatectomía cefálica. En el análisis histológico, se confirmó el diagnóstico de paraganglioma gangliocítico metastásico por la presencia patognomónica de tres estirpes celulares (epiteliales, ganglionares y Schwann-like). Dado su buen pronóstico, asociado con baja quimiosensibilidad, no recibió tratamiento adyuvante. Resultados. Durante el seguimiento, el paciente no presentó complicaciones tardías, ni signos de recidiva después de un año de la intervención. Conclusión. El paraganglioma gangliocítico es una entidad potencialmente maligna, que requiere un correcto estudio de extensión y un seguimiento estrecho a largo plazo

Introduction. Gangliocytic paraganglioma is a rare histological entity, with the duodenum being its main extra-nodal location. Clinical case. This is a 54-year-old man who presented with abdominal pain and upper gastrointestinal bleeding. A suspicious ampuloma lesion was diagnosed, for which a pancreaticoduodenectomy was performed. In the histological analysis, the diagnosis of metastatic gangliocytic paraganglioma was confirmed by the pathognomonic presence of three cell lines (epithelial, ganglionic, and Schwann-like). Given his good prognosis associated with low chemosensitivity, he did not receive adjuvant treatment. Results. During follow-up, the patient did not present late complications or signs of recurrence one year after the intervention. Conclusion. Gangliocytic paraganglioma is a potentially malignant entity that requires a correct extension study and close long-term follow-up

Pancreatoduodenectomía de urgencia. Revisión de 2 casos clínicos

Introducción: La pancreatoduodenectomía de urgencia (PDDU) es una cirugía reservada para lesiones graves pancreatoduodenales secundarias a trauma, lesiones inflamatorias o posterior a procedimientos endoscópicos. Objetivo: Describir dos casos clínicos en los que se realizó PDDU. Casos Clínicos: Se reportan 2 casos clínicos en los cuales se requirió una PDD. En el primer caso secundario a úlcera duodenal perforada que comprometía más del 50% del lumen asociado a biliperitoneo y fistula duodenal sin control; y en el segundo, a consecuencia de un trauma por herida de bala con perforación duodenal, íleon distal y desgarro de 1,5 cm en cabeza de páncreas. Discusión: En la actualidad no existe un consenso sobre las indicaciones de PPDU, sin embargo esta compleja cirugía representa una opción de tratamiento en pacientes bien seleccionados, cuando la cirugía de control de daños y los intentos de controlar la necrosis y fistulas duodenales han fracasado. Conclusión: El tratamiento de una lesión pancreática y duodenal compleja puede requerir PDDU. Sin embargo, en pacientes inestables se debe considerar una cirugía en dos tiempos por un equipo de cirujanos experimentados.

Introduction: Emergency pancreaticoduodenectomy (UPDD) is a surgery reserved for severe pancreaticoduodenal injuries secondary to trauma, inflammatory injuries or after endoscopic procedures. Aim: To describe two clinical cases in which PDDU was performed. Clinical Cases: 2 clinical cases are reported in which a PDDU was required. The first case was secondary to a perforated duodenal ulcer that compromised more than 50% of the lumen associated with biliperitoneum uncontrolled duodenal fistula; in the second one, as a consequence of a gunshot wound trauma with duodenal perforation, distal ileum and a 1.5 cm tear in the head of pancreas. Discussion: Currently there is no consensus on the indications for UPDD, however this complex surgery represents a treatment option in well-selected patients, when damage control surgery and attempts to control necrosis and duodenal fistulas have failed. Conclusión: Treatment of a complex pancreatic and duodenal injury may require pancreatoduodenectomy. However, in unstable patients, a two-stage surgery should be considered by an experienced surgical team.

Alternative fistula risk score and first postoperative day drain fluid amylase as predictors of pancreatic fistula after pancreaticoduodenectomy / Escore alternativo de risco de fístula e níveis de amilase do fluido de drenagem no primeiro dia de pós-operatório como preditores de fístula pancreática após pancreaticoduodenectomia

ABSTRACT BACKGROUND: The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula. AIMS: The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied. METHODS: This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models. RESULTS: The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase. CONCLUSION: The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.

RESUMO RACIONAL: A alta morbimortalidade da pancreaticoduodenectomia está associada, principalmente, à anastomose pancreatojejunal, a mais frágil e suscetível a complicações como a fístula pancreática pós-operatória clinicamente relevante (clinically relevant postoperative pancreatic fistula - CR-POPF). OBJETIVOS: O escore alternativo de risco de fístula (alternative fistula risk score) e os níveis de amilase do fluido de drenagem no primeiro dia pós-operatório (first postoperative day drain fluid) são preditores da ocorrência de fístula pancreática pós-operatória clinicamente relevante. Nenhum consenso foi alcançado sobre qual das pontuações é um melhor preditor; além disso, seu poder preditivo combinado permanece obscuro. Até onde sabemos, essa associação ainda não havia sido estudada. MÉTODOS: Este estudo avaliou o efeito preditivo do escore alternativo de risco de fístula e/ou do fluido de drenagem no primeiro dia pós-operatório em uma coorte retrospectiva de 58 pacientes após pancreaticoduodenectomia. Os testes de Shapiro-Wilk e Mann-Whitney foram aplicados para avaliar a distribuição das amostras e para comparar as medianas, respectivamente. A curva de características operacionais do receptor e a matriz de confusão foram utilizadas para analisar os modelos preditivos. RESULTADOS: Os valores do escore alternativo de risco de fístula não foram estatisticamente diferentes entre os pacientes dos grupos fístula pancreática pós-operatória clinicamente relevante e não- fístula pancreática pós-operatória clinicamente relevante (teste U de Mann-Whitney 59,5, p=0,12). Os valores de fluido de drenagem no primeiro dia pós-operatório foram estatisticamente diferentes entre os grupos fístula pancreática pós-operatória clinicamente relevante e não- fístula pancreática pós-operatória clinicamente relevante (teste U de Mann-Whitney 27, p=0,004). O escore alternativo de risco de fístula e fluido de drenagem no primeiro dia pós-operatório foram independentemente menos preditivos para fístula pancreática pós-operatória clinicamente relevante, em comparação com escore alternativo de risco de fístula + fluido de drenagem no primeiro dia pós-operatório combinados. CONCLUSÕES: O modelo combinado envolvendo escore alternativo de risco de fístula>20% + fluido de drenagem no primeiro dia pós-operatório=5.000 U/L foi o preditor mais eficaz da ocorrência de fístula pancreática pós-operatória clinicamente relevante após pancreaticoduodenectomia.

From left to right. para-aortic lymph nodes sampling during pancreatoduodenectomy for pancreatic cancer / Da esquerda para a direita. ressecção de linfonodos para-aórticos durante duodenopancreatectomia para câncer pancreático

ABSTRACT BACKGROUND: Para-aortic lymph nodes involvement in pancreatic head cancer has been described as an independent adverse prognostic factor. To avoid futile pancreatic resection, we systematically perform para-aortic lymphadenectomy as a first step. AIMS: To describe our technique for para-aortic lymphadenectomy. METHODS: A 77-year-old female patient, with jaundice and resectable pancreatic head adenocarcinoma, underwent pancreaticoduodenectomy associated with infracolic lymphadenectomy. RESULTS: The infracolic anterior technique has two main advantages. It is faster and prevents the formation of postoperative adhesions, which can make subsequent surgical interventions more difficult. CONCLUSIONS: We recommend systematic para-aortic lymphadenectomy as the first step of pancreaticoduodenectomy for pancreatic head adenocarcinoma by this approach.

RESUMO RACIONAL: O envolvimento dos gânglios linfáticos para-aórticos no câncer da cabeça do pâncreas tem sido descrito como um fator prognóstico adverso independente. Para evitar a ressecção pancreática inútil, realizamos sistematicamente linfadenectomia para-aórtica. OBJETIVOS: Descrever a técnica de linfadenectomia para-aórtica. MÉTODOS: Paciente do sexo feminino, 77 anos, com quadro de icterícia e adenocarcinoma da cabeça do pâncreas ressecável, submetida à duodenopancreatectomia associada à linfadenectomia infracólica. RESULTADOS: Esta técnica anterior infracólica tem duas vantagens principais: é mais rápida e evita a formação de aderências pós-operatórias, o que pode dificultar as intervenções cirúrgicas subsequentes. CONCLUSÕES: Recomendamos a linfadenectomia para-aórtica sistemática como o primeiro passo da duodenopancreatectomia para o adenocarcinoma da cabeça do pâncreas por esta abordagem.

The experience and enlightenment of robotic surgery training course in the University of Pittsburgh Medical Center / 中华医学教育探索杂志

Objective:To introduce the experience of robotic surgery training course in the University of Pittsburgh Medical Center.Methods:The specific process of the training course was introduced in detail, and the results of the training course were summarized and analyzed. A total of 15 surgeons completed the first step of the training (operation table simulation training), 14 (93.3%) completed the second step (pancreatoduodenectomy tissue anastomosis simulation training), and 196 cases of tissue anastomosis simulation training were completed. Statistical analysis was performed using STATA and SPSS software. Wilcoxon rank sum test was used to analyze the data.Results:The average scores of the surface validity Likert scale for anastomosis simulation training were: (15/20) for Pancreaticojejunostomy (PJ), (15/20) for Gastrojejunostomy (GJ), and (17/20) for Hepatocholangiojejunostomy (HJ). In the PJ and GJ simulation training, compared with the gold standard, the error rate and OSATS score were significantly improved ( P > 0.05), and the operation time was not significantly reduced ( P < 0.05). In HJ simulation training, the error rate, OSATS score and operation time did not show significant improvement ( P < 0.05). However, it could be concluded that all the simulation operations performed by the trainees after the training were better than the first time, when linear regression and quadratic fitting models were performed to analyze continuous trainings of the trainees as a group. Conclusion:The training course carried out by the University of Pittsburgh Medical Center is valid and effective, and it can be used for reference to explore a way for the development of robotic surgery fitting to the real conditions of our country.

Application of single-layer with full thickness of duct-to-mucosa pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy / 中华胰腺病杂志

Objective:To explore the clinical efficacy and safety of single-layer with full thickness of duct-to-mucosa pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy.Methods:The clinical data of 45 patients who underwent laparoscopic pancreaticoduodenectomy with the procedures of single-layer with full thickness in Second Hospital of Hebei Medical University from Jan 2020 to Jan 2022 were retrospectively collected and compared with 45 matched patients with traditional two-layer pancreaticojejunostomy.Results:The laparoscopic pancreaticoduodenectomy procedures were successfully performed in all the 90 cases. The mean operation time (285.6±92.4 minutes) and the media pancreaticojejunostomy time 20(15, 35) minutes) of the single-layer with full thickness pancreaticojejunostomy group were shorter than those of the two-layer pancreaticojejunostomy group [the mean operation time: 317.0±85.5 minutes, the media pancreaticojejunostomy time: 46(30, 58) minutes] with significantly statistical differences (all P value<0.05). There were no significantly statistical differences on intraoperative blood loss, the postoperative complications or hospital stay between the two groups. Conclusions:Compared with traditional pancreaticojejunostomy, the single-layer with full thickness of duct-to-mucosa pancreaticojejunostomy is simple and safe, which has the advantage of easy manipulation and less time-consuming and can be recommended for laparoscopic procedures.

Application of a novel modified Blumgart anastomosis in laparoscopic pancreaticoduodenectomy / 中国医师进修杂志

Objective:To investigate the efficacy and safety of a novel modified Blumgart pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy (LPD).Methods:Between May 2021 and January 2022, 13 successive cases from Lihuili Hospital Affiliated to Ningbo University who underwent LPD were enrolled in this retrospective study. The study retrospectively analyzed the demographic characteristics, perioperative outcomes, and pathological results of these cases.Results:Twenty patients underwent LPD success-fully and one required conversion to open surgery. The operative time was (308.6 ± 61.7) min. The duration for PJ was (26.7 ± 4.3) min. The estimated blood loss was (188.1 ± 94.2) ml. The postoperative hospital stay was (14.2 ± 3.5) d. There was one case of biochemical leakage and no case of grade B or grade C pancreatic fistula.Conclusions:The new method is safe, simple and feasible. The novel method could reduce the incidence of pancreatic fistula and other complications after LPD.

Correlation of the duration of preoperative biliary drainage and postoperative complications after pancreaticoduodenectomy / 肿瘤研究与临床

Objective:To investigate the effect of the duration of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy.Methods:The clinical data of 102 patients with benign and malignant hepatopancreatic ductal periampullary tumors who underwent pancreaticoduodenectomy and preoperative biliary drainage in Beijing Friendship Hospital, Capital Medical University from January 2016 to July 2020 were retrospectively analyzed. According to the median duration of preoperative biliary drainage, the patients were divided into short-term drainage group (≤ the median duration of biliary drainage) and long-term drainage group (> the median duration of biliary drainage). The general data, the effect of biliary drainage, inflammation-related indicators and postoperative complications were compared between the two groups. Multivariate logistic regression was used to screen the risk factors related to the postoperative severe complications.Results:Of the 102 patients, 68 (66.7%) were males and 34 (33.3%) were females, with a median age of 63 years (43-80 years). The median duration of preoperative biliary drainage was 14 d. There were 68 patients in short-term drainage group and 34 patients in long-term drainage group. There were no statistically significant differences in age, gender, body mass index (BMI), hypertension, diabetes mellitus, surgery history of upper abdominal, American Society of Anesthesiologists (ASA) grade, carcinoembryonic antigen, carbohydrate antigen 125, alpha-fetoprotein, prothrombin time, pancreaticojejunostomy method, operation time, and pathological type between the two groups (all P > 0.05). However, patients in long-term drainage group had higher conversion rate, more blood loss and longer hospital stay compared with those in short-term drainage group (all P < 0.05). Before biliary drainage, alanine aminotransferase (ALT) level in short-term drainage group was higher than that in long-term drainage group ( Z = -2.59, P = 0.009), and there were no statistically significant differences in aspartate aminotransferase (AST), albumin (ALB), total bilirubin (TB) and direct bilirubin (DB) levels between the two groups before biliary drainage (all P > 0.05). After biliary drainage, DB in short-term drainage group was higher than that in long-term drainage group ( Z = -3.34, P = 0.001), and there was no statistically significant difference in ALT, AST, ALB, TB levels between the two groups (all P > 0.05). There were no statistically significant differences in the levels of white blood cells, neutrophils, lymphocytes and the ratio of neutrophils to lymphocytes between the two groups on the 1st and 3rd day after the operation (all P > 0.05). The total incidence of postoperative related complications in short-term drainage group and long-term drainage group was 63.2% (43/68), 70.6% (24/34), respectively, and the difference was statistically significant ( χ2 = 0.54, P = 0.461); the incidences of bile leakage, abdominal or gastrointestinal bleeding, intra-abdominal infection, delayed gastric emptying, all grades of pancreatic leakage, grade B and C pancreatic leakage were not statistically different between the two groups (all P > 0.05); the incidence of severe postoperative related complications in short-term drainage group was higher than that in long-term drainage group [27.9% (19/68) vs. 8.8% (3/34), χ2 = 4.90, P = 0.027]. Multivariate logistic regression analysis showed that the long-term preoperative biliary drainage was an independent protective factor for postoperative severe complications (long-term drainage vs. short-term drainage: OR = 0.253, 95% CI 0.066-0.975, P = 0.046), while BMI ( OR = 1.174, 95% CI 0.986-1.398, P = 0.071) and pathological type (benign or borderline vs. malignant tumor: OR = 0.247, 95% CI 0.043-1.419, P = 0.117) were not independent influencing factors for postoperative severe complications. Conclusions:Short-term biliary drainage (≤14 d) is a risk factor for postoperative severe complications in patients with hepatopancreatic ductal periampullary tumor undergoing preoperative biliary drainage. Preoperative biliary drainage time is not associated with postoperative total complications, pancreatic leakage, bile leakage, abdominal or gastrointestinal bleeding, intra-abdominal infection, delayed gastric emptying.

Retrospective analysis of endoscopic retrograde cholangiopancreatography after pancreaticoduodenectomy / 中华消化内镜杂志

Objective:To evaluate the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) after pancreaticoduodenectomy and endoscopic selection strategies.Methods:Clinical data of 34 patients treated with ERCP after pancreaticoduodenectomy at the Endoscopic Center of the First Affiliated Hospital of Air Force Medical University from January 2013 to December 2021 were retrospectively analyzed. The success rates of endoscopic insertion, diagnosis, treatment and ERCP, and the incidence of adverse events were analyzed.Results:Fifty ERCP treatments were performed in 34 patients. The success rates of endoscopic insertion, diagnosis, treatment, and ERCP after pancreaticoduodenectomy were 92.0% (46/50), 93.5% (43/46), 88.4% (38/43) and 76.0% (38/50), respectively. The success rates of ERCP assisted with colonoscope and balloon-assisted enterosocpe were 76.0% (19/25) and 75.0% (18/24), respectively. There were 3 adverse events, including 1 case of anastomotic mucosa tear during surgery, 1 case of cardiopulmonary arrest and 1 case of postoperative cholangitis.Conclusion:ERCP is effective and safe after pancreaticoduodenectomy in general. ERCP assisted with colonoscope and balloon-assisted colonoscope shows similar success rate after pancreaticoduodenectomy.

A modified Blumgart procedure in laparoscopic pancreaticoduodenectomy / 中华普通外科杂志

Objective:To evaluate A modified Blumgart pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy.Methods:The clinical data of 81 patients undergoing laparoscopic pancreaticoduodenectomy in Zhengzhou University Affiliated Cancer Hospital from Jan 2019 to Jan 2022 were retrospectively analyzed. Among them, 26 patients underwent modified Blumgart anastomosis and 55 underwent conventional Blumgart anastomosis.The data of demographics, liver function, pancreatic texture, operational result and complications were compared between the two groups.Results:The preoperative data (body mass index, preoperative albumin, prealbumin, transaminase, total bilirubin) between two groups were comparable ( P>0.05). There was no significant difference in pancreatic texture, pancreatic duct diameter and intraoperative blood loss between the two groups ( P>0.05). The modified group had shorter total operation time ( P<0.05), shorter pancreaticojejunostomy time ( P<0.05), shorter postoperative hospital stay ( P<0.05). The incidence of total pancreatic fistula and biochemical fistula in the modified group were lower than those in the conventional group ( P<0.05). There was no significant difference in the incidence of B/C grade pancreatic fistula and bile leakage, postoperative bleeding, infection and delayed gastric emptying between the two groups ( P>0.05). Conlusions:The modified Blumgart pancreaticojejunostomy during laparoscopic pancreaticoduodenectomy is safe, easy to do and time saving. While the incidence of postoperative pancreatic fistula with clinical significance　and other major complications were similar to traditional Blumgart procedure.

Clinical characteristics and management strategies of late bleeding after laparoscopic pancreaticoduodenectomy / 中华肝胆外科杂志

Objective:To study the clinical characteristics and management strategies of late bleeding after laparoscopic pancreaticoduodenectomy (LPD).Methods:The clinical data of 58 patients with post-pancreaticoduodenectomy hemorrhage (PPH) admitted to the Department of Hepatobiliary Surgery of the Second Hospital of Hebei Medical University from March 2018 to March 2022 were retrospectively analyzed, including 42 males and 16 females, aged (61.88±11.02) years old. According to the occurrence of intra-abdominal erosion factors (e.g., pancreatic fistula, biliary fistula, gastrointestinal anastomotic fistula, intra-abdominal abscess), patients were divided into the erosion group ( n=42) and non-erosion group ( n=16). All patients underwent standard lymphadenectomy. Clinical data including the PPH time-point, occurrence of rebleeding, and treatment outcomes were accessed. The management strategies of PPH in the two groups of patients were analyzed. Results:The PPH time-point in the erosion group and non-erosion patients was 8.00 (5.00, 19.25) d and 21.50 (12.75, 26.75) d, respectively ( P=0.001). PPH can occurred within one month after surgery in both erosion and non-erosion groups. In the erosion group, 31 cases (73.81%, 31/42) were treated by re-operation, two (4.76%, 2/42) by interventional radiology and nine (21.43%, 9/42) with conservative protocol, respectively. In the non-erosion group, five cases (31.25%, 5/16) were treated by re-operation, seven (43.75%, 7/16) by interventional radiology and four (25.00%, 4/16) with conservative protocol, respectively. The incidence of re-bleeding is higher in the erosion group [47.6% (20/42) vs 12.5% (2/16), P<0.05]. Clinical manifestations, sites and severity of bleeding, and treatment outcomes were also different in the erosion and non-erosion groups (all P<0.05). Conclusions:The occurrence of intra-abdominal erosion factors can affect the clinical characteristics and treatment strategy of late bleeding after laparoscopic pancreaticoduodenectomy. Surgery remains the treatment of choice for post-pancreaticoduodenectomy hemorrhage either as an urgent or last resort.

Construction and validation of a nomogram prediction model for early recurrence of patients undergoing radical pancreaticoduodenectomy for pancreatic ductal adenocarcinoma / 中华肝胆外科杂志

Objective:To study the risk factors for early recurrence of patients undergoing radical pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) and construct a normogram model.Methods:Patients undergoing open radical PD for PDAC at Faculty of Hepato-Pancreato-Biliary Surgery, Chinese PLA General Hospital from January 2014 to December 2021 were retrospectively screened. A total of 213 patients were enrolled, including 145 males and 68 females, aged (58.4±9.8) years. Patients were divided into the early recurrence group ( n=59, recurrence within 6 months after surgery) and a control group ( n=154, no recurrence within 6 months after surgery). Using minimum absolute value convergence and selection operator regression (LASSO) and multi-factor logistic regression analysis, we screened out the best predictor of early recurrence after PD for PDAC, and then established a nomogram model. The effectiveness of the model was validated by receiver operating characteristic (ROC) curve, calibration curves, and decision analysis curves. Results:Multivariate logistic regression analysis showed that patients with obstructive jaundice, vascular invasion, massive intraoperative bleeding, high-risk tumors (poorly differentiated or undifferentiated), high carbohydrate antigen 19-9 to total bilirubin ratio, and high fibrinogen and neutrophil to lymphocyte ratio scores had a higher risk of early postoperative recurrence. Based on the indexes above, a nomogram prediction model was constructed. The area under the ROC curve was 0.797 (95% CI: 0.726-0.854). Validation of the calibration curve exhibited good concordance between the predicted probability and ideal probability, decision curve analysis showed that the net benefits of the groupings established according to the model were all greater than 0 within the high risk threshold of 0.08 to 1.00. Conclusion:The nomogram for predicting early recurrence after PD for PDAC has a good efficiency, which could be helpful to screen out the high-risk patients for adjuvant or neoadjuvant therapy.

Value of the imaging features of extrapancreatic nerve plexus in predicting the early postoperative recurrence of ductal adenocarcinoma of pancreatic head / 中华肝胆外科杂志

Objective:To study the value of imaging features of extrapancreatic nerve plexus in predicting early postoperative recurrence of ductal adenocarcinoma of pancreatic head.Methods:The clinical, imaging and pathological data of patients with ductal adenocarcinoma of pancreatic head undergoing pancreati-coduodenectomy at the Hepatobiliary Pancreatic Center of Beijing Tsinghua Changgung Hospital, Tsinghua University from January 2014 to April 2022 were retrospectively analyzed. A total of 73 patients were included, including 51 males and 22 females, aged (66.1±9.0) years old. The patients were followed up by telephone or outpatient review, who were divided into two groups according to the recurrence within 6 months after surgery: the recurrence group ( n=26) and the non-recurrence group ( n=47). Streaks or soft-tissue densities in the distribution area of extrapancreatic nerve plexus, difference in CT values between the portal and arterial phases of the distribution area of extrapancreatic nerve plexus, maximum tumor diameter, and regional lymph node enlargement were compared between the two groups. Results:The incidences of streaks or soft-tissue densities showing in the distribution area of extrapancreatic nerve plexus were 80.8%(21/26) in the recurrence group and 51.1%(24/47) in the non-recurrence group, respectively. A CT value difference ≥15 HU between the portal and arterial phases of the distribution area of extrapancreatic nerve plexus occurred in 50.0%(13/26) patients of the recurrence group and 25.5%(27/47) of the non-recurrence group, respectively. Maximum tumor diameter ≥25 mm were found in 80.8% (21/26) patients of the recurrence group and 57.4% (27/47) of the non-recurrence group, respectively. ≥3 reginal lymph node enlargement showed in 65.4% (17/26) patients of the recurrence group and 31.9% (15/47) of the non-recurrence group, respectively (all P<0.05). The risk of early postoperative recurrence increased in patients with a CT value difference ≥15 HU between the portal and arterial phases of the distribution area of extrapancreatic nerve plexus ( OR=3.609, 95% CI: 1.099-11.855), and regional lymph node enlargement ≥ 3 ( OR=4.665, 95% CI: 1.400-15.545) (all P<0.05). And these two independent risk factors were combined to predict early postoperative recurrence of ductal adenocarcinoma of pancreatic head with an area under receiver operating characteristic curve of 0.748, sensitivity of 92.3%, and specificity of 48.9% ( P<0.001). Conclusion:≥ 15 HU CT value difference between the portal and arterial phases of the distribution area of extrapancreatic nerve plexus and ≥ 3 regional lymph node enlargement are independent risk factors for the early postoperative recurrence of pancreatic head ductal adenocarcinoma, which could provide more predictive information preoperatively.

Risk factors of pancreatic fistula after pancreaticoduodenectomy and pancreaticojejunostomy / 中华肝胆外科杂志

Objective:To analyze the risk factors of clinically-relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) and penetrating pancreaticojejunostomy (PPJ).Methods:The clinical data of 108 patients who underwent PD and PPJ in the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Wannan Medical College from January 2017 to October 2022 were analyzed retrospectively, including 65 males and 43 females, aged 65.5 (54.2, 72.0) years. The incidences of POPF, biliary fistula, abdominal bleeding and other related complications were reviewed. The related factors of CR-POPF were analyzed by univariate analysis, and the statistically significant factors were included in multivariate logistic regression analysis.Results:A total of 108 patients were successfully treated with PD, including laparoscopic PD in 76 cases (70.4%) and open PD in 32 cases (29.6%). PPJ was performed in PD, including the continuous fashion in 39 cases (36.1%), intermittent fashion in 49 cases (45.4%) and modified continuous fashion in 20 cases (18.5%). The operation time was 390.0 (314.0, 480.0) min, the intraoperative blood loss was 200.0 (100.0, 384.0) ml, the postoperative hospital stay was 12.0 (10.0, 15.0) d, and the incidence of POPF (grade B + C) was 11.1% (12/108). Body mass index, pancreatic CT value and pancreatic duct size were the significant factors of CR-POPF (all P<0.05). Multivariate logistic regression analysis showed that age ( OR=0.895, 95% CI: 0.822-0.975), pancreatic CT value ( OR=0.812, 95% CI: 0.698-0.946) and pancreatic duct size ( OR=0.457, 95% CI: 0.220-0.952) were risk factors of CR-POPF after PPJ (all P<0.05). Conclusion:PPJ is a safe method of pancreaticoenterostomy, and CR-POPF may be related to younger patients, lower pancreatic CT value and the smaller pancreatic duct size.

Analysis of pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy / 中华肝胆外科杂志

Laparoscopic pancreaticoduodenectomy is an important surgical undertaking, mostly used for benign and malignant tumors in the pancreatic head and periampullary region. The postoperative pancreatic fistula is the main factor to cause death after pancreaticoduodenectomy, and pancreaticojejunostomy is an independent risk factor for pancreatic fistula. In order to reduce the incidence of pancreatic fistula, surgeons have proposed dozens of pancreaticojejunostomy, but so far there are no randomized trials proved which method of pancreaticojejunostomy is better than the others. This article reviews the methods and characteristics of different pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy.