Perioperative outcomes of robotic versus video-assisted thoracoscopic surgery in non-small cell lung cancer patients after neoadjuvant chemoimmunotherapy.

Background: Limited data are available regarding perioperative outcomes in patients with non-small cell lung cancer (NSCLC) who undergo robotic-assisted thoracic surgery (RATS) after neoadjuvant chemoimmunotherapy. This study aimed to compare the perioperative outcomes of RATS and video-assisted thoracic surgery (VATS) in NSCLC patients after neoadjuvant chemoimmunotherapy. Methods: The study involved consecutive NSCLC patients treated with minimally invasive surgery (MIS) after neoadjuvant chemoimmunotherapy at a high-volume single center from September 2020 to October 2022. Short-term effects, including demographic, perioperative and pathological parameters, were compared between the RATS group and the VATS group. Results: A total of 119 patients were included in this study. Of these, 33 (27.7%) patients received RATS and 86 (72.3%) patients received VATS. Major pathological response (MPR) and pathological complete response (pCR) rates were comparable between the two groups. The RATS group had a higher number of dissected lymph nodes (21 vs. 18, P=0.03) and lymph node stations (7 vs. 6, P=0.004) compared with the VATS group but no differences were found in perioperative outcomes. Conclusions: These findings suggest that both RATS and VATS are safe and feasible options for NSCLC patients who have received neoadjuvant chemoimmunotherapy. Furthermore, RATS may offer advantages over VATS in patients who require a more extensive lymph node dissection.

Spread Through Air Spaces in Stage I Pulmonary Large Cell Neuroendocrine Carcinoma.

BACKGROUND: Pulmonary large cell neuroendocrine carcinoma (LCNEC) represents an exceptionally aggressive and infrequent variant within the realm of non-small cell lung cancer, necessitating surgical intervention as the primary therapeutic approach. However, the postoperative management strategy for early-stage patients continues to be a subject of intense debate and uncertainty. METHODS: A retrospective analysis was conducted on a cohort of patients diagnosed with LCNEC who underwent surgical resection at Shanghai Pulmonary Hospital between July 2018 and June 2022. Comprehensive assessments, encompassing univariate and multivariate analyses, were performed to evaluate the prognostic significance of these indicators in patient clinical profiles, overall survival (OS), and disease-free survival (DFS). RESULTS: A comprehensive screening effort identified 171 patients with LCNEC, with 70 stage I patients meeting the criteria for inclusion in the final cohort. Of these, 11 patients (15.7%) presented with combined LCNEC, and 59 (84.3%) exhibited pure LCNEC. Univariate and multivariate analyses both unveiled that spread through air spaces (STAS) status emerged as an independent prognostic determinant for both DFS (P = .003) and OS (P = .013), whereas histologic subtype independently predicted OS (P = .011). Subgroup survival analyses further underscored that the advantageous effects of postoperative chemotherapy were significantly pronounced exclusively among STAS-positive patients, showcasing a statistically significant enhancement in DFS (P = .047) and OS (P = .018). CONCLUSIONS: STAS may serve as an adverse prognostic factor in stage I LCNEC patients, potentially offering guidance for postoperative chemotherapy decisions.

Machine learning prediction model of major adverse outcomes after pediatric congenital heart surgery: a retrospective cohort study.

BACKGROUND: Major adverse postoperative outcomes (APOs) can greatly affect mortality, hospital stay, care management and planning, and quality of life. This study aimed to evaluate the performance of five machine learning (ML) algorithms for predicting four major APOs after pediatric congenital heart surgery and their clinically meaningful model interpretations. METHODS: Between August 2014 and December 2021, 23 000 consecutive pediatric patients receiving congenital heart surgery were enrolled. Based on the split date of 1 January 2019, the authors selected 13 927 participants for the training cohort, and 9073 participants for the testing cohort. Four predefined major APOs including low cardiac output syndrome (LCOS), pneumonia, renal failure, and deep venous thrombosis (DVT) were investigated. Thirty-nine clinical and laboratory features were inputted in five ML models: light gradient boosting machine (LightGBM), logistic regression (LR), support vector machine, random forest, and CatBoost. The performance and interpretations of ML models were evaluated using the area under the receiver operating characteristic curve (AUC) and Shapley Additive Explanations (SHAP). RESULTS: In the training cohort, CatBoost algorithms outperformed others with the mean AUCs of 0.908 for LCOS and 0.957 for renal failure, while LightGBM and LR achieved the best mean AUCs of 0.886 for pneumonia and 0.942 for DVT, respectively. In the testing cohort, the best-performing ML model for each major APOs with the following mean AUCs: LCOS (LightGBM), 0.893 (95% CI: 0.884-0.895); pneumonia (LR), 0.929 (95% CI: 0.926-0.931); renal failure (LightGBM), 0.963 (95% CI: 0.947-0.979), and DVT (LightGBM), 0.970 (95% CI: 0.953-0.982). The performance of ML models using only clinical variables was slightly lower than those using combined data, with the mean AUCs of 0.873 for LCOS, 0.894 for pneumonia, 0.953 for renal failure, and 0.933 for DVT. The SHAP showed that mechanical ventilation time was the most important contributor of four major APOs. CONCLUSIONS: In pediatric congenital heart surgery, the established ML model can accurately predict the risk of four major APOs, providing reliable interpretations for high-risk contributor identification and informed clinical decisions-making.

The impact of oncogenic driver mutations on neoadjuvant immunotherapy outcomes in patients with resectable non-small cell lung cancer.

BACKGROUND: Neoadjuvant immunotherapy has been demonstrated to be effective and safe in resectable non-small cell lung cancer (NSCLC) patients. However, the presence of different oncogenic driver mutations may affect the tumor microenvironment and consequently influence the clinical benefit from immunotherapy. METHODS: This retrospective study included consecutive NSCLC patients (stage IIA to IIIB) who underwent radical surgery after receiving neoadjuvant immunotherapy at a single high-volume center between December 2019 and August 2022. Pathological response and long-term outcomes were compared based on the driver oncogene status, and RNA sequencing analysis was conducted to investigate the transcriptomic characteristics before and after treatment. RESULTS: Of the 167 patients included in this study, 47 had oncogenic driver mutations. KRAS driver mutations were identified in 28 patients, representing 59.6% of oncogenic driver mutations. Of these, 17 patients had a major pathological response, which was significantly higher than in the non-KRAS driver mutation group (60.7% vs. 31.6%, P = 0.049). Multivariate Cox regression analysis further revealed that the KRAS driver mutation group was an independent prognostic factor for prolonged disease-free survival (hazard ratio: 0.10, P = 0.032). The median proportion of CD8+ T cells was significantly higher in the KRAS driver mutation NSCLCs than in the non-driver mutation group (18% vs. 13%, P = 0.030). Furthermore, immune-related pathways were enriched in the KRAS driver mutation NSCLCs and activated after immunotherapy. CONCLUSION: Our study suggests that NSCLC patients with KRAS driver mutations have a superior response to neoadjuvant immunotherapy, possibly due to their higher immunogenicity. The findings highlight the importance of considering oncogenic driver mutations in selecting neoadjuvant treatment strategies for NSCLC patients.

The ICU-CARB score: a novel clinical scoring system to predict carbapenem-resistant gram-negative bacteria carriage in critically ill patients upon ICU admission.

BACKGROUND: With the widespread spread of carbapenem-resistant gram-negative bacteria (CR-GNB) in medical facilities, the carriage of CR-GNB among critically ill patients has become a significant concern in intensive care units (ICU). This study aimed to develop a scoring system to identify CR-GNB carriers upon ICU admission. METHODS: Consecutive critically ill patients admitted to the ICU of Shanghai Ruijin Hospital between January 2017 and December 2020 were included. The patients were then divided into training and testing datasets at a 7:3 ratio. Parameters associated with CR-GNB carriage were identified using least absolute shrinkage and selection operator regression analysis. Each parameter was assigned a numerical score ranging from 0 to 100 using logistic regression analysis. Subsequently, a four-tier risk-level system was developed based on the cumulative scores, and assessed using the area under the receiver operating characteristic curve (AUC). RESULTS: Of the 1736 patients included in this study, the prevalence of CR-GNB carriage was 10.60%. The clinical scoring system including seven variables (neurological disease, high-risk department history, length of stay ≥ 14 days, ICU history, invasive mechanical ventilation, gastrointestinal tube placement, and carbapenem usage) exhibited promising predictive capabilities. Patients were then stratified using the scoring system, resulting in CR-GNB carriage rates of 2.4%, 12.0%, 36.1%, and 57.9% at the respective risk levels (P < 0.001). Furthermore, the AUC of the developed model in the training set was calculated to be 0.82 (95% CI, 0.78-0.86), while internal validation yielded an AUC of 0.83 (95% CI, 0.77-0.89). CONCLUSIONS: The ICU-CARB Score serves as a straightforward and precise tool that enables prompt evaluation of the risk of CR-GNB carriage at the time of ICU admission, thereby facilitating the timely implementation of targeted pre-emptive isolation.

Drain fluid volume combined with amylase level predicts clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A retrospective clinical study.

BACKGROUND AND AIM: Several indicators are recognized in the development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). However, drain fluid volume (DFV) remains poorly studied. We aimed to discover the predictive effects of DFV and guide clinical management. METHODS: We retrospectively reviewed the clinical data of patients that received PD between January 2015 and December 2019 in a high-volume center. DFV was analyzed as a potential risk factor and postoperative short-term outcomes as well as drain removal time were compared stratified by different DFV levels. Receiver operating characteristic curves and area under curves (AUC) were compared for DFV alone and DFV combined with drain fluid amylase (DFA). Subgroup analysis of DFV stratified by DFA evaluated the predictability of CR-POPF. RESULTS: CR-POPF occurred in 19.7% of 841 patients. Hypertension, postoperative day 3 (POD3) DFA ≥ 300 U/L, and POD3 DFV ≥ 30 mL were independent risk factors, while pancreatic main duct diameter ≥ 3 mm was a protective factor. POD3 DFV ≥ 30 mL increased the overall occurrences of CR-POPF and major complications (P = 0.017; P = 0.029). POD3 DFV alone presented a low predictive value (AUC 0.602), while POD3 DFV combined with DFA had a high predictive value (AUC 0.759) for CR-POPF. Subgroup analysis showed that the combination of POD3 DFV ≥ 30 mL and DFA ≥ 300 U/L led to higher incidences of CR-POPF (P = 0.003). CONCLUSION: CR-POPF is common after PD, and high DFV combined with DFA may predict its occurrence and facilitate appropriate management.

Urine proteomic analysis of the rat e-cigarette model.

Background: We were curious if the urinary proteome could reflect the effects of e-cigarettes on the organism. Methods: Urine samples were collected from a rat e-cigarette model before, during, and after two weeks of e-cigarette smoking. Urine proteomes before and after smoking of each rat were compared individually, while the control group was set up to rule out differences caused by rat growth and development. Results: Fetuin-B, a biomarker of chronic obstructive pulmonary disease (COPD), and annexin A2, which is recognized as a multiple tumour marker, were identified as differential proteins in five out of six smoking rats on day 3. To our surprise, odourant-binding proteins expressed in the olfactory epithelium were also found and were significantly upregulated. Pathways enriched by the differential proteins include the apelin signalling pathway, folate biosynthesis pathway, arachidonic acid metabolism, chemical carcinogenesis-DNA adducts and chemical carcinogenesis-reactive oxygen species. They have been reported to be associated with immune system, cardiovascular system, respiratory system, etc. Conclusions: Urinary proteome could reflect the effects of e-cigarettes in rats.

Arginine-carboxylated pullulan, a potential antibacterial material for food packaging.

Pullulan possesses excellent film-forming properties and oxygen isolation capabilities. However, it exhibits limited antibacterial properties and poor water resistance, thereby hindering its application in the field of food preservation. In this study, we synthesized D-arginine-succinic anhydride-pullulan (Arg-SA-Pul) by carboxylating pullulan and subsequently grafting it with D-arginine. The antimicrobial test demonstrated that Arg-SA-Pul exhibited comparable antibacterial activity against Escherichia coli and Staphylococcus aureus. Using Arg-SA-Pul as the primary material and glycerol as the plasticizer, we fabricated an antibacterial film via the tape casting method. The film's light transmittance, water solubility, and water vapor permeability were evaluated. Compared to the natural pullulan film, the Arg-SA-Pul film exhibited lower vapor permeability. Additionally, we conducted preservation tests on cherries by coating them with the Arg-SA-Pul film. The results demonstrated that the Arg-SA-Pul film exhibited a significant preservation effect on cherries and effectively delayed their ripening and senescence. In the future, the Arg-SA-Pul film could be employed as a bacteriostatic preservation material to extend the shelf life of fruits.

Preoperative Prognostic Nutritional Index and Nomogram for Predicting the Risk of Postoperative Complications in Patients With Crohn's Disease.

INTRODUCTION: Patients with Crohn's disease (CD) are at a high risk of having postoperative complications. Preoperative prognostic nutritional index (PNI) has been extensively studied for postoperative complications in malignancies but seldom for CD. METHODS: Patients who underwent CD-related bowel surgery for the first time in our hospital were retrospectively enrolled from January 2013 to October 2019. Differences in clinical features in low-PNI (≤34) and high-PNI (>34) groups were compared. A prognostic nomogram was then established to explore the risk factors and their assignments of postoperative complications. RESULTS: A total of 124 patients who underwent CD-related bowel surgery in our hospital from January 2013 to October 2019 were enrolled. Of these patients, 39 (31.5%) were categorized in the low-PNI group. The serum albumin levels (23.4 ± 4.8 vs 35.8 ± 5.2 g/L, P < 0.001), hemoglobin levels (98.0 ± 24.1 vs 115.8 ± 22.2 g/L, P < 0.001), and white blood cell counts (8.3 ± 5.4 × 10 9 vs 6.3 ± 3.0 × 10 9 , P = 0.009) of the patients in the low-PNI group were lower than those in the high-PNI group. Postoperative complications were observed in 35 cases of the total cohort, 20 of 39 (51.3%) in the low-PNI group, and 15 of 85 (17.6%) in the high-PNI group ( P < 0.001). A prognostic nomogram was built through least absolute shrinkage and selection operator regression. The nomogram revealed a significant difference in the length of postoperative stay between patients with high-risk postoperative complications and those with low-risk postoperative complications (17.07 ± 24.73 vs 10.36 ± 4.51, P = 0.02). DISCUSSION: PNI is closely associated with postoperative complications in patients with CD. Its inclusion in a prognostic nomogram provides a convenient mechanism to predict postoperative complications in patients with CD undergoing surgery.

Postpancreatectomy Acute Pancreatitis After Pancreaticoduodenectomy: A Distinct Clinical Entity.

OBJECTIVE: This study aimed to characterize postpancreatectomy acute pancreatitis (PPAP) after pancreaticoduodenectomy (PD) in a high-volume center. BACKGROUND: The International Study Group for Pancreatic Surgery (ISGPS) has recently proposed a new definition and grading scale of PPAP, but specific studies are lacking. METHODS: Patients who underwent PD from 2020 to 2021 were retrospectively reviewed. PPAP was defined based on the International Study Group for Pancreatic Surgery definition: sustained elevation of serum amylase levels for least the first 48 hours postoperatively and radiologic alterations consistent with PPAP. RESULTS: Among a total of 716 patients who were finally analyzed, PPAP occurred in 152 (21.2%) patients. Patients with PPAP were associated with significantly higher incidences of postoperative pancreatic fistula (POPF) (40.8% vs 11.7%, P <0.001), major complications (13.8% vs 6.6%, P =0.004), and biliary leak (11.8% vs 4.6%, P =0.001). Among them, 8 patients developed grade C PPAP leading to organ failure, reoperation, or death. Patients developing PPAP alone also demonstrated a statistically significantly increased rate of major complications than those without PPAP or POPF. In contrast, no differences were found in postoperative outcomes in patients with POPF in terms of whether they were associated with PPAP. CONCLUSION: PPAP is a distinct complication after PD with distinctive clinical outcomes. A part of PPAP presents as an inflammatory process in the early postoperative period but sometimes could lead to necrotizing pancreatitis or other severe clinical scenarios, and another part of PPAP would lead to anastomotic failure that accounts for a great proportion of POPF occurrence.

Risk factors for and prognostic values of postoperative acute kidney injury after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: A retrospective, propensity score-matched cohort study of 1312 patients.

BACKGROUND: While an association between postoperative acute kidney injury (AKI) and adverse events exists, the incidence and impact of postoperative AKI after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma remain unclear. This study aimed to diagnose AKI and investigate the risk factors for and prognostic value of postoperative AKI. METHODS: Clinical characteristics of patients who underwent pancreaticoduodenectomy between 2013 and 2020 at a high-volume centre were collected retrospectively. The Kidney Disease Improving Global Outcomes criteria were used to diagnose AKI. A 1:2 propensity score matching (PSM) was used to minimise bias between the AKI and non-AKI groups. Short-term surgical and long-term survival outcomes were compared between groups. Multivariate logistic regression analysis assessed the independent risk factors for AKI development, major complications, and 30-day mortality. RESULTS: Postoperative AKI occurred in 10.7% of 1312 patients. Total bilirubin level > 250 µmol/L (odds ratio [OR]: 3.24; p < 0.001), estimated glomerular filtration rate < 60 ml/min/1.73 m2 (OR: 2.30; p = 0.048), and intraoperative estimated blood loss >1000 ml (OR: 2.96; p = 0.001) were independent risk factors for postoperative AKI. After PSM, higher incidences of major complications (p < 0.001) and 30-day mortality (p < 0.001) were observed in the AKI group than in the non-AKI group. There was no difference in long-term overall survival outcomes between both groups (p = 0.535). AKI was an independent predictor of major complications (OR: 3.06; p < 0.001) and 30-day mortality (OR: 2.87; p = 0.034). CONCLUSIONS: Postoperative AKI is common after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma and has a predictive effect on major complications and 30-day mortality. Therefore, prevention and proper management of postoperative AKI are required in clinical practice.

The Impact of Additional Para-aortic Dissection During Pancreaticoduodenectomy for Resectable Pancreatic Cancer.

BACKGROUND: The short-term outcome and long-term survival of pancreaticoduodenectomy with additional para-aortic dissection (PAD) for patients with resectable pancreatic cancer remain obscure. PATIENTS AND METHODS: Consecutive patients who underwent radical pancreaticoduodenectomy for resectable pancreatic cancer in a single high-volume center during a 7-year period were included retrospectively. Both short- and long-term effects of PAD were compared between the PAD group and the no PAD group. Then, the PAD group was divided into the non-metastatic para-aortic lymph node (PALN-) group and the metastatic PALN (PALN+) group to further analyze the prognosis of PALN+. RESULTS: Of the 909 included patients, 280 (30.8%) underwent PAD during pancreaticoduodenectomy. The PAD group had a higher rate of intra-abdominal infection compared with the no PAD group (28.6% vs. 20.7%, P = 0.009) but no differences were found in the incidence of other complications. The overall survival (OS) and recurrence-free survival (RFS) were also comparable between the two groups. Subgroup analysis showed that patients with PALN+ had a worse OS than patients in the PALN- group (median of 14 vs. 20 months, P = 0.048). Multivariate Cox regression analysis further revealed that PALN+ was an independent adverse predictor of OS (hazard ratio: 1.70, P = 0.007). CONCLUSIONS: This study suggests that the addition of PAD during pancreaticoduodenectomy does not improve the prognosis of patients with resectable pancreatic cancer and may lead to an increased risk of infection. However, the accurate preoperative assessment and appropriate treatment strategy for patients with PALN+ need further investigation due to the poor prognosis.

Long-term outcomes of standard versus extended lymphadenectomy in pancreatoduodenectomy for pancreatic ductal adenocarcinoma: A Chinese multi-center prospective randomized controlled trial.

INTRODUCTION: The value of extended lymphadenectomy in pancreatoduodenectomy (PD) has been discussed by five randomized controlled studies. However, the limitations in the studies made their conclusions not sufficiently reliable. OBJECTIVES: This multi-center randomized controlled study was designed to clarify the efficacy of extended lymphadenectomy in PD for pancreatic ductal adenocarcinoma (PDAC). METHODS: From December 2016 to October 2018, 170 consecutive patients undergoing PD were enrolled and randomized to standard or extended lymphadenectomy for the treatment of PDAC from three high-volume institutions in China. Demographic, pathological characteristics and survival data of these patients were collected and analyzed. No neoadjuvant treatment was performed. The primary endpoint was the 3-year overall survival. RESULTS: For all patients, the 3-year survival rate was 25.88 %. There was no between-group difference in 3-year survival rate (27.16 % vs 24.72 % p = 0.717). The median survival time for the standard group was 18 months, while for the extended group it was 15 months. The demographic and pathological characteristics were similar between groups. More positive lymph nodes could be found in the extended group (2.34 ± 3.46 vs 1.41 ± 2.12, p = 0.035), which led to nodule stage migration. All patients received chemotherapy. But patients in extended group were more likely to fail in completion of all-cycles chemotherapy before recurrence (31.46 % vs 17.28 %, p = 0.032). Incomplete chemotherapy before recurrence, higher N status and abnormal CA125 were independent risk factors for 1-year survival (p < 0.001, 95 % CI 0.076-0.368; p = 0.017, 95 % CI 1.113-3.021; p = 0.021, 95 % CI 1.136-4.960, respectively), which was higher in the standard group (75.31 % vs 58.43 %, p = 0.020). CONCLUSION: The extended lymphadenectomy in PD did not improve the long-term survival in patients with PDAC. Patients with extended lymphadenectomy had a worse 1-year overall survival. However, the nodule stage migration facilitated by the extended lymphadenectomy contributed to the precise tumor staging.

Changes in the urinary proteome of rats after short-term intake of magnesium L-threonate(MgT).

Introduction: Magnesium (Mg) is an important mineral in living organisms. Magnesium has multiple functions in the human body, wherein it plays an important therapeutic and preventive role in a variety of diseases. Methods: Urine samples of rats before and after gavage of magnesium L-threonate (MgT) were collected, and the urinary proteome was identified using the LC-MS/MS technique and analyzed using various databases. Results and discussion: The results illustrated that the urinary proteome of rats was significantly altered after short-term intake of magnesium supplements and that the differential proteins and the biological functions were related to magnesium. This study innovatively establishes a method to study nutrients from the perspective of urine proteomics. This work demonstrates that the urinary proteome is capable of reflecting the effects of nutrient intake on the organism in a more systematic and comprehensive manner and has the potential to provide clues for clinical nutrition research and practice.

Engineering an AI-based forward-reverse platform for the design of cross-ribosome binding sites of a transcription factor biosensor.

A cross-ribosome binding site (cRBS) adjusts the dynamic range of transcription factor-based biosensors (TFBs) by controlling protein expression and folding. The rational design of a cRBS with desired TFB dynamic range remains an important issue in TFB forward and reverse engineering. Here, we report a novel artificial intelligence (AI)-based forward-reverse engineering platform for TFB dynamic range prediction and de novo cRBS design with selected TFB dynamic ranges. The platform demonstrated superior in processing unbalanced minority-class datasets and was guided by sequence characteristics from trained cRBSs. The platform identified correlations between cRBSs and dynamic ranges to mimic bidirectional design between these factors based on Wasserstein generative adversarial network (GAN) with a gradient penalty (GP) (WGAN-GP) and balancing GAN with GP (BAGAN-GP). For forward and reverse engineering, the predictive accuracy was up to 98% and 82%, respectively. Collectively, we generated an AI-based method for the rational design of TFBs with desired dynamic ranges.

Oncological outcomes of robotic pancreatectomy in patients with pancreatic cancer who receive adjuvant chemotherapy: A propensity score-matched retrospective cohort study.

BACKGROUND: Limited data are available regarding long-term oncological outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) who undergo robotic pancreatectomy (RP). METHOD: All patients who underwent RP and open pancreatectomy (OP) for resectable PDAC between January 2011 and December 2019 were included. The RP group was matched 1:1 with OP group by propensity score matching (PSM). The oncological outcomes were collected and analyzed. RESULTS: Overall, 1606 patients were included in this study. After PSM, a well-balanced cohort of 335 patients in each group was selected for further analysis. The RP group had shorter operative time (210 min vs. 240 min, P < 0.001), lower estimated blood loss (200 ml vs. 300 ml, P = 0.011), lower wound infection rates (4.5% vs. 10.1%, P = 0.005) and shorter length of postoperative hospital stay (15 days vs. 17 days, P = 0.001) compared to the OP group, with no significant differences in other perioperative outcomes. OS was comparable between the two groups (31 months vs. 28 months, P = 0.077); however, RFS was improved in the RP group (17 months vs. 14 months, P = 0.015). Subgroup analysis showed that patients who received adjuvant chemotherapy (AC) in the RP group had better RFS than the similar patient cohort in the OP group (17 months vs. 14 months, P = 0.024). CONCLUSION: Robotic pancreatectomy is safe and oncologically effective for resectable PDAC. OS was comparable between RP and OP, and RFS was improved in the RP group, especially in patients who receive AC.

The Impact of Time Interval Between First Extubation and Reintubation on Bronchopulmonary Dysplasia or Death in Very Low Birth Weight Infants.

Objective: To explore the association between time from first extubation to reintubation and moderate-to-severe bronchopulmonary dysplasia (BPD) or death in very low birth weight infants. Study Design: Infants weighing <1,500 g at birth, requiring mechanical ventilation, and undergoing their initial extubation were retrospectively included from January 2014 to December 2021. They were divided into the moderate-to-severe BPD/death group and the comparison group according to the incidence of moderate-to-severe BPD or death. We defined time to reintubation as the time interval between first extubation and reintubation. In a stepwise multivariate logistic regression analysis, we examined the association between time to reintubation and moderate-to-severe BPD/death using different observation windows after initial extubation (24-h intervals). Results: A total of 244 infants were recruited, including 57 cases in the moderate-severe BPD/death group and 187 cases in the comparison group, and 93 (38.1%) cases were reintubated at least one time after their first extubation. Univariate analysis showed that reintubation rates within different observation windows in the moderate-to-severe BPD/death group were statistically significantly (p < 0.05) higher than those in the comparison group. Multivariate regression analysis showed that reintubation within observation windows 48 h or 72 h post-extubation was an independent risk factor in moderate-to-severe BPD/death and death, but not moderate-to-severe BPD. When the time window was 48 h, the probability of moderate-to-severe BPD/death [odds ratio (OR): 3.778, 95% confidence interval (CI): 1.293-11.039] or death (OR: 4.734, 95% CI: 1.158-19.354) was highest. While after extending the observation window to include reintubations after 72 h from initial extubation, reintubation was not associated with increased risk of moderate-to-severe BPD and/or death. Conclusions: Not all reintubations conferred increased risks of BPD/death. Only reintubation within 72 h from initial extubation was independently associated with increased likelihood of moderate-to-severe BPD/death and death in very low birth weight infants, and reintubation within the first 48 h post-extubation posed the greatest risk.

Machine learning algorithms as early diagnostic tools for pancreatic fistula following pancreaticoduodenectomy and guide drain removal: A retrospective cohort study.

OBJECTIVE: Clinically relevant postoperative pancreatic fistula (CR-POPF) remains the major cause of morbidity following pancreaticoduodenectomy (PD). Several model score systems such as the Fistula Risk Score (FRS) have been developed to predict CR-POPF using preoperative and intraoperative data. Machine learning (ML) algorithms are increasingly applied in the medical field and they could be used to assess the risk of CR-POPF, identify clinically meaningful data and guide drain removal. METHODS: Data from consecutive patients who underwent PD between January 1, 2010 and March 31, 2021 at a single high-volume center was collected retrospectively in this study. Demographics, clinical features, intraoperative parameters, and laboratory values were used to conduct the ML model. Four different ML algorithms (CatBoost, lightGBM, XGBoost and Random Forest) were used to train this model with cross-validation. RESULTS: A total of 2421 patients with 62 clinical parameters were enrolled in this ML model. The majority of patients (76.3%) underwent open PD while others underwent robot-assisted PD. CR-POPF occurred in 424 (17.5%) patients. The CatBoost algorithm outperformed other algorithms with a mean area under the receiver operating characteristic curve (AUC) of 0.81 (95% confidence interval: 0.80-0.82) from the 5-fold cross-validation procedure. In the test dataset, the CatBoost algorithm also achieved the best mean-AUC of 0.83. The most important value was mean drain fluid amylase (DFA) in the first seven postoperative days (POD). The performance of models that used only preoperative data and intraoperative data was marginally lower than that of models that used combined data. CONCLUSION: Our ML algorithms could be applied as early diagnostic tools for CR-POPF in patients who underwent PD. Such real-time clinical decision support tools can identify patients with a high risk of CR-POPF, help in developing the perioperative management plan and guide the optimal timing of drain removal.