Current status and progress of pancreatic surgery in the past 20 years / 中华消化外科杂志

Pancreatic surgery is an important specialty in the field of general surgery. As the anatomical location of pancreas is deeply and complex, and the diseases of pancreatic surgery is various kinds of and serious with high difficulty in surgery, the development of pancreatic surgery is slowly in the past. In the recent 20 years, with the deepening of basic and clinical researches in related fields, researchers' cognition of pancreatic diseases has gradually deepened. A series of new con-cepts and techniques have been applied to pancreatic surgery, making pancreatic surgery enter a rapid development stage. At the same time, researchers also recognize that the existing medical concepts and technical means are not sufficient to solve all clinical problems. Therefore, the cancer of pancreatic surgery in China can be alive and flourishing by grasping the opportunities, making continuous exploration and innovation.

Pancreatitis aguda necrotizante infectada. Desbridamiento retroperitoneal video asistido / Infected necrotizing pancreatitis. Video-assisted retroperitoneal debridement

Resumen El tratamiento escalonado de la pancreatitis aguda necrotizante infectada consiste en el uso de antibióticos de amplio espectro, drenaje y necrosectomía mínimamente invasiva, si fuese necesaria. Esto ha reemplazado a la cirugía abierta como el estándar de tratamiento. El desbridamiento retroperitoneal video asistido (VARD), es una forma de necrosectomía quirúrgica mínimamente invasiva. Presentamos una serie de 5 casos (2 mujeres y 3 varones) con pancreatitis aguda grave y necrosis pancreática infectada tratados de forma escalonada y VARD. El rango de edad fue de 27 a 60 años. Todos los pacientes tuvieron pancreatitis de etiología biliar. El rango del APACHE II fue de 16 a 20. El rango del tiempo para el drenaje percutáneo lumbar fue de 4 a 7 semanas. Hubo una complicación del drenaje percutáneo (fistula duodenal) que se resolvió con tratamiento médico. Los cultivos de todas las necrosis fueron positivos. El tiempo para la realización del VARD tuvo un rango de 6 a 10 semanas. Un paciente requirió dos procedimientos. Hubo dos fístulas pancreáticas tipo B asociadas al VARD, que se trataron conservadoramente. No hubo mortalidad. A largo plazo, dos pacientes fueron diagnosticados de insuficiencia pancreática exocrina y endocrina. Concluimos que en los pacientes con necrosis pancreática infectada que requieran desbridamiento, el VARD es una alternativa segura, efectiva y con buenos resultados a largo plazo.

Abstract The step-up approach for infected necrotizing pancreatitis, consisting of broad-spectrum antibiotics, drainage followed, if necessary, by minimally invasive necrosectomy, has replaced open surgery as the standard of management. Video-assisted retroperitoneal debridement (VARD) is a surgical minimally invasive necrosectomy. This is a 5 cases series (2 female and 3 males) with severe acute pancreatitis and infected pancreatic necrosis who underwent step up approach and VARD. The age ranged from 27 to 60 years old. Al patients had biliary pancreatitis. APACHE II ranged from 16 to 20. The time to percutaneous lumbar drainage ranged from 4 to 7 weeks. There was one complication associated with percutaneous drainage (duodenal fistula) with nonoperative management. All necrotizing pancreatitis had positive cultures. The time to perform VARD ranged from 6 to 10 weeks. One patient required two procedures. There were two type B pancreatic fistulas associated with VARD, managed nonoperatively. There was no mortality. During long-term follow-up two patients were diagnosed with exocrine and endocrine pancreatic insufficiency. We conclude that VARD is a safe and effective procedure in patients with infected necrotizing pancreatitis requiring debridement, and with good long-term outcomes.

Risk factors for open pancreatic necrosectomy in patients with severe acute pancreatitis: An analysis based on the surgical step-up approach / 临床肝胆病杂志

ObjectiveTo investigate the risk factors for open pancreatic necrosectomy (OPN), an effective treatment method for severe acute pancreatitis (SAP) after the failure of percutaneous catheter drainage (PCD), in patients with SAP. MethodsA retrospective analysis was performed for 156 patients with SAP who underwent surgical intervention based on the step-up approach in The Affiliated Hospital of Zunyi Medical University from January 1, 2010 to June 30, 2018, and according to whether OPN was performed, the patients were divided into PCD group with 126 patients and PCD+OPN group with 30 patients. Related clinical data were collected, including age, sex, etiology, blood calcium on admission, white blood cell count on admission, whether CTSI score was ＞7, APACHE-Ⅱ score, Ranson score, presence or absence of peripancreatic fluid accumulation, presence or absence of infection, presence or absence of multiple organ failure (MOF), and whether PCD was performed at more than 1 week after admission. The t-test was used for comparison of continuous data between groups, and the chi-square test was used for comparison of categorical data between groups; a multivariate logistic regression analysis was used to determine the independent predictive factors for OPN. ResultsThe probability of OPN was 19.2% for SAP patients in the later stage. Compared with the PCD+OPN group, the PCD group had a significantly lower proportion of patients with MOF on admission ［27.0% (34/126) vs 70.0% (21/30), χ2=19.642, P＜0.01］ and a significantly higher proportion of patients undergoing PCD at less than 1 week after admission ［61.9% (78/126) vs 20.0% (6/30), χ2=17.121, P＜0.01］. MOF on admission (odds ratio ［OR］=5.343, 95% confidence interval ［CI］: 1.832-15.583, P＜0.05), initial PCD performed at more than 1 week after admission (OR= 5.518, 95% CI: 1.742-17.477, P＜0.05), and infection on admission (OR=5.016, 95% CI: 1.322-19.378, P＜0.05) were independent risk factors for subsequent OPN in SAP patients. ConclusionSAP with MOF on admission, initial PCD performed at more than 1 week after admission, and SAP with infection on admission are independent risk factors for subsequent OPN in SAP patients undergoing PCD in the early stage based on the step-up approach. Timely identification of related risk factors helps to grasp the timing of OPN in clinical practice and improve the clinical prognosis of SAP patients.

Significance of Combined Use of Kamishoyosan and Tokishakuyakusan for General Infertility Treatment / 日本東洋医学雑誌

We aimed to clarify the significance of using Kampo therapy centered on kamishoyosan and tokishakuyakusan together with general infertility treatment. The subjects were 41 women who visited a Kampo outpatient clinic for infertility and received general infertility treatment with Kampo therapy (Kampo group). The control group was 781 women who received only general infertility treatment at the same time (non-Kampo group). In comparing both groups, we conducted a retrospective survey on the pregnancy rate by cycle and the pregnancy rate by prescription. The pregnancy rate in the first cycle was 24.4% in the Kampo group and 8.5% in the non-Kampo group, and the pregnancy rate was higher in the Kampo group (P = 0.003). There was no difference in pregnancy rates after the second cycle. The pregnancy rate by prescription was 26.7% for kamishoyosan, 22.2% for tokishakuyakusan, and 8.5% for the non-Kampo group. In the comparison between the first cycle pregnant group and the non-pregnant group, the qi counter flow score was clearly higher in the first cycle pregnant group (P = 0.012). It is suggested that combined use of Kampo therapy including kamishoyosan and tokishakuyakusan may be effective from an early stage. Meanwhile, if pregnancy does not occur even after the combined use of Kamp therapy, it would be an opportunity to consider stepping up as Western medical therapy.

Step up approach for the management of late presentation of pancreatic trauma patients

Background: Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities and these injuries are often overlooked in cases with extensive multi-organ trauma. Our study was conducted to evaluate the outcome of a step-up approach in the management of pancreatic trauma patients with late presentation.Methods: The study included 15 patients who presented with grade III AAST delayed presentation of pancreatic trauma from September 2017 to 2019. In our step-up approach 2 staged procedure was done, firstly laparotomy with necrosectomy along with closure of proximal pancreatic duct with external drainage of pancreatic duct, in second stage Roux-en-Y pancreaticojejunostomy was done to drain the remnant pancreas as a definitive procedure 3 to 6 months after initial procedure.Results: In our study, blunt trauma abdomen (83.30%) (n=10) was the most common mode of injury. The main reason for delay in diagnosis of pancreatic trauma was delayed presentation of patient (83.3%) (n=10). Total of 4 patients were admitted to intensive care unit (ICU) at the time of admission. 10 patients underwent both the stages of step up approach management among which one patient had pancreatic fistula as a complication (n=1) (10%) and one patient had post-operative abscess as a complication (n=1) (10%). No mortality was noted in our study.Conclusions: The step-up approach discussed above proves to be beneficial towards management of patients with delayed presentation of pancreatic trauma in our setting.

Imaging features, when and how to perform minimally invasive intervention in infected pancreatic necrosis patients / 中国实用外科杂志

Recently,with the further understanding of infected pancreatic necrosis(IPN),pancreatologists have reached consensuses on that the presence of gas on CT imaging could be the golden standard diagnosis for IPN,the intervention timing for IPN should be delayed to four weeks later,and the step-up approach acts as the first standard treatment strategy for IPN.Whereas in clinical practice,there are substantial new challenges awaiting our solutions,for instance,the lack of accurate and specific diagnostic criteria for IPN without typical gas sign on CT imaging,whether the intervention of wall-off necrosis(WON)which got infected prematurely should be delayed to four weeks later?What's more,whether the endoscopy centered step-up approach is superior to the surgical step-up approach?Is it time to abandon open surgery in IPN management?If not,when should we switch to open necrosectomy?All of these questions are still full of controversies.

Interpretation of American Gastroenterological Association Clinical Practice update: management of pancreatic necrosis in acute pancreatitis patients / 中国实用外科杂志

American Gastroenterological Association(AGA)has published the latest clinical practice update in Gastroenterology in August 2019. The purpose of this AGA clinical practice update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition. In recent decades,with the improvement in clinical practice,the management of pancreatic necrosis in patients with acute pancreatitis(AP)has undergone great changes. The well-defined step-up approach has been more advocated rather than the traditional open surgery. The treatment of pancreatic necrosis mainly includes two aspects,conservative methods, which consist of antimicrobial therapy as well as nutrition support,and invasive interventions.Drainage and/or debridement of pancreatic necrosis is best indicated in patients with infected necrosis or patients with sterile pancreatic necrosis and persistent clinical symptoms,which need proactive management. A step-up approach consists of percutaneous drainage or endoscopic transmural drainage, followed by direct endoscopic/percutaneous minimally invasive necrosectomy, and then surgical debridement is reasonable. As for the comparison between percutaneous surgical or endoscopic step-up approach,no studies have shown that there are differences between the two in the main clinical outcomes,for instance,mortality. Hence,the choice of specific treatment strategy in different AP centers depends mainly on their available clinical expertise and medical resources.

Surgical intervention strategy for severe acute pancreatitis in minimally invasive era / 中华外科杂志

With the development of minimally invasive concept, the treatment mode of severe acute pancreatitis has changed greatly. The tendency of surgical intervention has changed from excessive intervention to inadequate intervention. The timing of intervention has changed from earlier to later, and the mode of intervention has changed from openness as the main way to minimally invasive as the guidance. The transformation of surgical intervention tendency conforms to both minimally invasive trend and the step-up approach, but there are still some shortcomings: inadequate surgical intervention, inappropriate timing and indications, and over dependence on minimally invasive surgery. Correctly grasping the indications of surgical intervention, accurately grasping the timing of surgical intervention, and reasonably choosing the mode of surgical intervention are the keys to solve the insufficiency of surgical intervention. Laying emphasis on multidisciplinary team and correctly recognizing the role and status of surgical intervention can effectively reduce the mortality of severe acute pancreatitis patients.

Early Biologic Treatment in Pediatric Crohn's Disease: Catching the Therapeutic Window of Opportunity in Early Disease by Treat-to-Target / 대한소아소화기영양학회지

The emergence of mucosal healing as a treatment goal that could modify the natural course of Crohn's disease and the accumulating evidence showing that biologics are most effective in achieving mucosal healing, along with the success of early treatment regimens for rheumatoid arthritis, have led to the identification of early Crohn's disease and development of the concept of catching the therapeutic window during the early disease course. Thus, an increasing number of pediatric gastroenterologists are adopting an early biologic treatment strategy with or without an immunomodulator. Although early biologic treatment is effective, cost and overtreatment are issues that limit its early use. Currently, there are insufficient data on who will benefit most from early biologics, as well as on who will not need early or even any biologics. For now, top-down biologics should be considered for patients with currently known high-risk factors of poor outcomes. For other patients, close, objective monitoring and accelerating the step-up process by means of a treat-to-target approach seems the best way to catch the therapeutic window in early pediatric Crohn's disease. The individual benefits of immunomodulator addition during early biologic treatment should be weighed against its risks and decision on early combination treatment should be made after comprehensive discussion with each patient and guardian.

Microbiota transplantation: concept, methodology and strategy for its modernization

Fecal microbiota transplantation (FMT) has become a research focus of biomedicine and clinical medicine in recent years. The clinical response from FMT for different diseases provided evidence for microbiota-host interactions associated with various disorders, including Clostridium difficile infection, inflammatory bowel disease, diabetes mellitus, cancer, liver cirrhosis, gut-brain disease and others. To discuss the experiences of using microbes to treat human diseases from ancient China to current era should be important in moving standardized FMT forward and achieving a better future. Here, we review the changing concept of microbiota transplantation from FMT to selective microbiota transplantation, methodology development of FMT and step-up FMT strategy based on literature and state experts' perspectives.

Strategies to further improve the overall cure rate of acute pancreatitis / 中华消化外科杂志

Acute pancreatitis (AP) is a common clinical acute abdominal disease.To further improve its overall cure rate,severe acute pancreatitis (SAP) should be paid more attention.In early inflammatory reaction period of SAP,comprehensive treatment in ICU should be strengthened,including adequate fluid resuscitation,early viscera function protection,effective nutritional support and dealing with abdominal compartment syndrome.Surgeons should be responsible in the treatment of infection period of SAP,and seize the timing of surgical intervention correctly.Pluralistic debridement model should be set up,which is mainly based on "step-up" strategy and combined with minimally invasive and multi-disciplinary.In addition,late complications of SAP should be prevented and treated with caution when they occur.The whole SAP treatment system should be based on the multi-disciplinary team (MDT),which requires fully cooperation of each department.Moreover,medical unions at different levels should be established to realize prompt network consultation or referral.In this way,case fatality rate of SAP can be reduced and overall cure rate of AP can be improved,thus benefiting the patients to the maximum extent.

Research advances in minimally invasive treatment of acute pancreatitis / 中华肝胆外科杂志

The "step-up approach" concept in acute pancreatitis treatment has been widely accepted.Recently minimally invasive treatment plays a crucial role in acute pancreatitis treatment.The application of minimally invasive treatment significantly reduced the trauma and related complications caused by surgery and enhanced the prognosis.Currently,variety of minimally invasive approaches are specific and effective.This review summarized the therapeutic methods as well as the advantages and limitations of minimally invasive treatment.We aim to help clinicians balance the pros and cons and choose the individualized way to improve the prognosis.

Necrotizing pancreatitis: description of videoscopic assisted retroperitoneal debridement (vard) technique with covered metallic stent / Pancreatite necrosante: descrição da técnica de debridamento videoendoscópico retroperitoneal (vard) assistida com stent metálico recoberto

ABSTRACT Background : Acute pancreatitis is the third most common gastrointestinal disorder requiring hospitalization in the United States, with annual costs exceeding $2 billions. Severe necrotizing pancreatitis is a life-threatening complication developed in approximately 20% of patients. Its mortality rate range from 15% in patients with sterile necrosis to up 30% in case of infected one associated with multi-organ failure. Less invasive treatment techniques are increasingly being used. These techniques can be performed in a so-called step-up approach. Aim: To present the technique for videoscopic assisted retroperitoneal debridement (Vard technique) with covered metallic stent in necrotizing pancreatitis. Method: A guide wire was inserted through the previous catheter that was removed in the next step. Afterwards, the tract was dilated over the guide wire. Then, a partially covered metallic stent was deployed. A 30 degrees laparoscopic camera was inserted and the necrosis removed with forceps through the expanded stent under direct vision. Finally, the stent was removed and a new catheter left in place. Result : This technique was used in a 31-year-old man with acute pain in the upper abdomen and diagnosed as acute biliary pancreatitis with infected necrosis. He was treated with percutaneous drains at weeks 3, 6 and 8. Due to partial recovery, a left lateral VARD was performed (incomplete by fixed and adherent tissue) at 8th week. As the patient´s inflammatory response was reactivated, a second VARD attempt was performed in three weeks later. Afterwards, patient showed complete clinical and imaging resolution. Conclusions : Videoassisted retroperitoneal necrosectomy using partially covered metallic stent is a feasible technique for necrotizing pancreatitis.

RESUMO Racional: A pancreatite aguda é a terceira doença gastrointestinal mais comum que requer hospitalização nos Estados Unidos, com custos anuais superiores a $ 2 bilhões. A pancreatite necrosante grave é uma complicação potencialmente fatal, desenvolvida em aproximadamente 20% dos pacientes. A taxa de mortalidade varia de 15% em pacientes com necrose estéril para 30% no caso de uma infecção infectada com falência multiorgânica. As técnicas de tratamento menos invasivas são cada vez mais utilizadas. Elas podem ser realizadas em uma abordagem chamada "step-up". Objetivo: Apresentar a técnica de desbridamento retroperitoneal assistido com videografia (técnica VARD) com stent metálico coberto em pancreatite necrosante. Método: Um fio guia é inserido através do cateter anterior que foi removido no próximo passo. Depois, o trajeto é dilatado sobre o fio guia. Em seguida, um stent metálico parcialmente coberto é implantado. Uma câmera laparoscópica de 30º é inserida e a necrose removida com fórceps através do stent expandido sob visão direta. Finalmente, o stent é removido e um novo cateter deixado no lugar. Resultado: Esta técnica foi utilizada em um homem de 31 anos com dor aguda na parte superior do abdome e diagnosticado como pancreatite biliar aguda com necrose infectada. Ele foi tratado com drenos percutâneos nas semanas 3, 6 e 8. Devido à recuperação parcial, realizou-se um VARD lateral esquerdo (incompleto por tecido fixo e aderente) na 8ª semana. À medida que a resposta inflamatória do paciente foi reativada, uma segunda tentativa VARD foi realizada em três semanas mais tarde. Posteriormente, o paciente apresentou resolução clínica e de imagem completa. Conclusão: A necrosectomia retroperitoneal assistida em vídeo com stent metálico parcialmente coberto é uma técnica viável para pancreatite necrosante.

A study of the role of intervention in the final outcome of acute pancreatitis.

Background: Acute pancreatitis is a common disease which varies in severity, from mild self-limiting pancreatic inflammation to severe pancreatic necrosis with life-threatening sequelae. As per the recent recommendations early intensive care with delayed intervention and step-up approach when indicated has definite survival advantages over the risks associated with early surgical procedures. The present study was aimed at evaluating the mortality and morbidity risk in patients undergoing procedural intervention in acute pancreatitis. Methods: This was a prospective study done in Sri Ramachandra Medical College and Hospital from April 2012- September 2014. All patients with a diagnosis of acute pancreatitis were included in this study. A total of 110 patients were analysed. Routine lab parameters, serum amylase, lipase, lipid profile, calcium, CRP, LDH, CT abdomen, CXR and 2D Echo was done for all patients. Procedural intervention was planned as per the guidelines. Results: Patients were given early intensive care as per the initial severity scores. 25 patients required intervention. Serum LDH, amylase, lipase and CT severity index were better predictors of requirement of intervention and death. Open necrosectomy was done in 15 patients (13.6%), laparoscopic necrosectomy in 3 patients (2.7%) and step up approach was tried in 7 patients (6.4%). Patients who were tried step up approach were monitored closely for any deterioration in their clinical condition to decide about surgery. 7 out of 8 patients who underwent surgery died. Alcoholic pancreatitis that underwent intervention had a high risk of mortality. Conclusions: Intensive care monitoring with delayed intervention had a better survival benefit. Patients subjected to minimally invasive interventions had a better chance of survival.

Chronic Low-dose Step-up Protocol in Treating Women with Unexplained Infertility: (37.5 Units Versus 75 Units of Follitropin Alpha as the Initial Dose).

Aims: To compare the treatment outcome of the 37.5 Units/day follitropin-alpha (Study Group) with 75 Units/day (Control Group) as the initial dose for chronic low-dose step-up ovulation induction for unexplained infertile, non-PCOS (polycystic ovarian syndrome) women. Methodology: Retrospective study and comparison of the patient characteristics and treatment outcome of 2 patient groups of 100 patient-cycles (Study and Control groups: Low-dose step-up cycles with initial doses of 37.5 Units/day and 75 Units/day, respectively). 95 (Study group) and 98 (Control group) ovulatory cycles were included in the final analysis. Results: Cycle cancellations were less common in the Study Group (6.3% vs 15.3%; P=0.02); those in the control group being mostly due to excessive response. The conception rates were similar: 11.5% and 11.2% in the study and the control groups, respectively. Total and mean daily gonadotropin used were lower in the study group (P=0.02 and P=0.04). 1 mild OHSS (Ovarian hyperstimulation syndrome) was observed in each group. There were no multiple pregnancies in either group. Conclusion: The initial daily dose of 37.5 Unit/day is more effective in achieving a unifollicular cycle while being as safe and effective as 75 Units/day; requiring a lower amount of gonadotropin for the conventional treatment of unexplained infertility in non-PCOS women.

Minimally invasive treatment of acute necrotizing pancreatitis / 国际外科学杂志

The treatment strategy for infected acute necrotizing pancreatitis is that enables recovery but at the same time limits the morbidity and mortality.The current gold standard remains open necrosectomy.Recent literature contains scattered reports of percutaneous drainage,endoscopic,and laparoscopic approaches to managing patients with this condition.This review addresses the role of minimally invasive approaches and treatment strategy in patients with infected acute necrotizing pancreatitis.

Effect of Step-up and Step-down Hyperthermia on Skin of Mice / 대한치료방사선과학회지

The usefulness of hypertemie for cancer therapy have well been established. The purpose of the present investigation was to ascess the effect of step-up (42 degrees C -> 44 degrees C sequence ) and step-down (44 degrees C -> 42 degrees C sequence) heating on the skin of the hind foot of the mouse. Hyperthermic treatments were given by immersion the hind foot of the mouse in circulating water baths. Skin response was studied by the leg reaction, which was scored according to a numerical scoring system proposed by Urano et al (1980). The results were as follws 1.The sking damage of 44 degrees C control group was more severe than 42degree C control group (p<0.0.5), except for 15min. heating group. 2. The skin damage of step-down group was more severe than step-up group (p<0.0.5). 3. The skin damage of 44 degrees C control group was more severe than step-up group when there is no difference in 44 degrees C heatingtime of step-up group from 44degree C control group (p<0.0.5). 4. In step-down group, the skin damage was more severe than 44degree C control group after preheating 45 min at 44 degrees C (p<0.0.5). Therefore, the above findings suggest the normal tissue damaged by step-up heating was correlated with heating time of post step-up. The dropping of heating temperature in late phase had more severe damage of the skin than that in early phase during hyperthermia, and so contineous control of satisfactory temperature should be considered as the one of the most important factor for prognosis, complications of clinical hyperthermia