Objective To investigate the effect of common iliac vein allograft replacing the portal vein-superior mesenteric vein transition area invaded by pancreatic cancer. Methods The clinical data of a patient with pancreatic cancer admitted to the Beijing Tsinghua Changgung Hospital in December 2021 who underwent pancreaticoduodenectomy combined with common iliac vein allograft replacing the junction of portal vein, superior mesenteric vein and splenic vein were analyzed retrospectively. The patient was a 77-year-old man who complained of “epigastric pain for 1 month and pancreatic mass was found for 1 week”. After admission, the patient was diagnosed with pancreatic cancer through inspection, and then the surgery was required. Preoperative examination and intraoperative exploration confirmed that the junction of portal vein, superior mesenteric vein, and spleen vein was invaded by tumor. In addition, the length of the invaded vessels measured by preoperative 3D reconstruction image was 5.5 cm, and the distance between the broken end of portal vein and the broken end of superior mesenteric vein measured was 4.5 cm during the operation. After tumor and vessels were resected, vascular anastomosis could not be performed directly. After accurate evaluation, pancreaticoduodenectomy combined with common iliac vein allograft replacing the junction of portal vein, superior mesenteric vein and splenic vein was performed. The operative time was 11 h, and the intraoperative blood loss was 400 mL. After the operation, the routine treatment was performed in ICU and was transferred to the general ward on the 7th day. Postoperative laboratory tests were performed to monitor liver function changes routinely, and imaging examination were was performed to monitor portal venous system blood flow. Results Postoperative complications such as biliary fistula, pancreatic fistula, hemorrhage, infection and thrombosis were not occurred. Postoperative pathological diagnosis: pancreatic ductal adenocarcinoma, medium-low differentiation. Enhanced CT reexamination on the 2nd and 13th day after the operation showed that the blood flow at the junction of portal vein, superior mesenteric vein and splenic vein of the common iliac vein allograft was unobstructed, and there was no stenosis or thrombosis at each anastomosis. Conclusions The application of common iliac vein allograft replacing the portal vein-superior mesenteric vein transition area invaded by pancreatic cancer is safe and feasible. The short-term efficacy is satisfactory, and long-term prognosis remains to be further observed.
ObjectiveTo compare the short- and long-term efficacy of artery-first approach pancreatico-duodenectomy (AF-PD) and standard approach pancreaticoduodenectomy (S-PD).MethodsThe PubMed, EMbase, The Cochrane Library, Web of Science, CBM, WanFang, and CNKI databases were searched, relevant literatures were included, and relevant data were extracted for meta-analysis.ResultsA total of 30 articles were included, including 2 750 cases underwent pancreaticoduodenectomy. The results of meta-analysis showed that in terms of short-term efficacy when compared with S-PD group, the AF-PD group had less intraoperative blood loss (WMD=–175.87, P<0.001), lower intraoperative blood transfusion rate (OR=0.36, P=0.002), higher R0 resection rate (OR=1.83, P<0.001), lower postoperative pancreatic leakage rate (OR=0.71, P=0.005), and shorter postoperative hospital stay (WMD=–2.69, P=0.007). However, there were no statistically significant differences in the operation time and overall postoperative complication rate between the two groups (P>0.05). In terms of long-term efficacy when compared with S-PD group, the AF-PD group had lower tumor local recurrence rate (OR=0.43, P=0.004) and tumor liver metastasis rate (OR=0.60, P=0.010), but had higher 1-year (OR=1.95, P=0.007), 2-year (OR=2.04, P<0.001), 3-year (OR=2.09, P=0.001), and 5-year (OR=2.06, P=0.003) overall survival rates, and there were no significant differences in the rates of lung metastasis and peritoneal metastasis between the two groups (P>0.05).ConclusionsAF-PD is better than S-PD in some short-term and long-term outcome indicators such as R0 resection rate, pancreatic leakage rate, overall survival rate, and so on. However, due to the limited quality of the included literatures, more high-quality studies are still needed to verify in the future.
ObjectiveTo review the recent research progress on prediction models for pancreatic fistula after pancreaticoduodenectomy and explore the potential application of prediction models in personalized treatment, aiming to provide useful reference information for clinical doctors to improve patient’s treatment outcomes and quality of life. MethodWe systematically searched and reviewed the literature on various prediction models for pancreatic fistula after pancreaticoduodenectomy in recent years domestically and internationally. ResultsSpecifically, the fistula risk score (FRS) and the alternative FRS (a-FRS), as widely used tools, possessed a certain degree of subjectivity due to the lack of an objective evaluation standard for pancreatic texture. The updated a-FRS (ua-FRS) had demonstrated superior predictive efficacy in minimally invasive surgery compared to the original FRS and a-FRS. The NCCH (National Cancer Center Hospital) prediction system, based on preoperative indicators, showed high predictive accuracy. Prediction models based on CT imaging informatics had improved the accuracy and reliability of predictions. Prediction models based on elastography had provided new perspectives for the assessment of pancreatic texture and the prediction of clinically relevant postoperative pancreatic fistula. The Stacking ensemble machine learning model contributed to the individualization and localization of prediction models. The existing pancreatic fistula prediction models showed satisfactory predictive efficacy, but there were still limitations in identifying high-risk patients for pancreatic fistula.ConclusionsAfter pancreaticoduodenectomy, pancreatic fistula remains a major complication that is difficult to overcome. The prevention of pancreatic fistula is crucial for improving postoperative recovery and reducing mortality rates. Future research should focus on the development and validation of pancreatic fistula prediction models, thereby enhancing their predictive power and increasing their predictive efficacy in different regional patients, providing a scientific basis for medical decision-making.
Objective To investigate the effect of sarcopenia on postoperative complications in patients undergoing pancreaticoduodenectomy（PD）. Methods The data of 225 patients who underwent pancreaticoduodenectomy in the Nanjing Hospital Affiliated to Nanjing Medical University (Nanjing First Hospital) from March 2012 to February 2020 were retrospectively analyzed. The total area of the skeletal muscle was measured by CT images at the level of the third lumbar vertebra for the diagnosis of sarcopenia. The patients were divided into sarcopenia group and non-sarcopenia group. The clinical data and surgical complications were compared between the two groups to explore the relationship between sarcopenia and postoperative complications. Results Compared with the non-sarcopenia group, the patients in the sarcopenia group were older and had lower hemoglobin concentration, lower serum albumin concentration, and higher total bilirubin levels (P<0.05). The incidences of clinically relevant pancreatic fistula (grade B and C fistula), pulmonary infection, atelectasis and hypoxemia in the sarcopenia group were significantly higher than those in the non-sarcopenia group (P<0.05). The length of ICU stay and perioperative mortality in the sarcopenia group were significantly higher than those in the non-sarcopenia group (P<0.05). Multivariate analysis showed that sarcopenia, preoperative total bilirubin level, pancreatic duct diameter and pancreatic texture were independent risk factors for clinically relevant pancreatic fistula (P<0.05). Sarcopenia, intraoperative blood loss and postoperative abdominal infection were independent risk factors for pulmonary complications after PD (P<0.05). Conclusions Sarcopenia is an independent risk factor for increased incidence of clinically relevant pancreatic fistula and pulmonary complications after PD. Strengthening perioperative nutritional therapy and rehabilitation exercise in patients with sarcopenia is of great significance to reduce postoperative complications of PD.
ObjectiveTo investigate safety and effectiveness of laparoscopic pancreaticoduodenectomy (LPD) in municipal hospitals.MethodsThe clinic data of patients underwent pancreatoduodenectomy in the Leshan People’s Hospital from November 2017 to January 2020 were retrospectively analyzed. The patients were divided into LPD group and open pancreaticoduodenectomy (OPD) group according to the operation methods, and the indicators of perioperative safety and effectiveness of the two groups were compared.ResultsA total of 72 patients were enrolled in this study, including 30 patients in the LPD group and 42 patients in the OPD group. There were no significant differences in the age, gender, and other baseline indicators between the two groups (P>0.05). Although the operative time of the LPD group was longer than that of the OPD group (P<0.05), the intraoperative blood loss in the LPD group was significantly less than that in the OPD group (P<0.05), the postoperative hospital stay, postoperative exhaust time, and postoperative ambulation time in the LPD group were shorter than those in the OPD group (P<0.05). And there were no significant differences in the terms of intraoperative red blood cell transfusion, intraoperative blood transfusion rate, postoperative ICU hospitalization time, hospitalization expenses, overall complications and specific complications (except incision infection rate of LPD group was significantly lower than OPD group, P=0.031) between the two groups (P>0.05). There were no significant differences in the positive rate of resection margin, number of lymph node dissection, and positive rate of lymph node between the two groups (P>0.05).ConclusionLPD has the same safety and effectiveness as OPD in the perioperative period in municipal hospitals, and is more conducive to postoperative recovery of patients.
ObjectiveTo summarize the current status and update of the use of medical imaging in risk prediction of pancreatic fistula following pancreaticoduodenectomy (PD).MethodA systematic review was performed based on recent literatures regarding the radiological risk factors and risk prediction of pancreatic fistula following PD.ResultsThe risk prediction of pancreatic fistula following PD included preoperative, intraoperative, and postoperative aspects. Visceral obesity was the independent risk factor for clinically relevant postoperative pancreatic fistula (CR-POPF). Radiographically determined sarcopenia had no significant predictive value on CR-POPF. Smaller pancreatic duct diameter and softer pancreatic texture were associated with higher incidence of pancreatic fistula. Besides the surgeons’ subjective intraoperative perception, quantitative assessment of the pancreatic texture based on medical imaging had been reported as well. In addition, the postoperative laboratory results such as drain amylase and serum lipase level on postoperative day 1 could also be used for the evaluation of the risk of pancreatic fistula.ConclusionsRisk prediction of pancreatic fistula following PD has considerable clinical significance, it leads to early identification and early intervention of the risk factors for pancreatic fistula. Medical imaging plays an important role in this field. Results from relevant studies could be used to optimize individualized perioperative management of patients undergoing PD.
ObjectiveTo investigate how to shorten the learning curve of the laparoscopic pancreaticoduodenectomy (LPD). MethodsClinical data of 5 patients who underwent the LPD in our hospital from May 2015 to November 2015 were retrospectively analyzed. ResultsThe mean age of 58.8 years old. There were four patients who were diagnosed with periampullary tumor, one patient was distal bile duct carcinoma. The median operative time was 588 min, the average blood loss was 290 mL, the time of feeding was 5 days, the mean hospital stay was 25 days. One case died of cardiovascular event on postoperative day 1. One patient had postoperative bleeding after LPD, who recovered smoothly after reoperation for hemostasis laparoscopiclly. Conciusions LPD needs basic learning curve. The key of this procedure are appropriate treatment of pancreatic head and digestive tract reconstruction. Rich operative experience of surgeon in pancreaticoduodenectomy, optimization of the operation process, skilled in laparoscopic procedures, appropriate cases, appropriate perioperative management, and steady surgical team are also important factor for the success of LPD and shorten learning curve.
Objective To investigate the cause, treatment, and prognosis of the postpancreaticoduodenectomy hemorrhage (PPH) . Method A total of 779 patients who underwent pancreaticoduodenectomy at Fudan University Shanghai Cancer Center between January 2015 and December 2016 were enrolled, and the data of them were retrospectively analyzed. Results Sixteen patients (PPH group) suffered from PPH and 763 patients didn’t suffered from PPH (non-PPH group) of 779 patients. There was no significant difference in the age, gender, type of disease, operative time, blood loss, and ratio of blood transfusion between the 2 groups (P>0.05), but the incidences of pancreatic fistula and delayed gastric emptying, postoperative drainage time, hospital stay, and mortality were all higher or longer in PPH group compared with non-PPH group (P<0.001). Of the 16 PPH patients, early haemorrhage occurred in 3 patients (including 2 patients with gastrointestinal haemorrhage and 1 patient with intra-abdominal haemorrhage) and delayed haemorrhage occurred in 13 patients (including 6 patients with gastrointestinal haemorrhage and 7 patients with intra-abdominal haemorrhage). All the 3 patients with early haemorrhage were cured by surgery. Of the 13 patients with delayed haemorrhage, 5 patients were cured by radiological intervention, 2 patients were cured by endoscopic hemostasis, and 3 patients were cured by conservative treatment, but 3 patients with sentinel bleeding died after interventional embolization+surgery. Conclusions The mortality of PPH is high. Surgery is optimal to early haemorrhage and radiological intervention is optimal to delayed haemorrhage, including embolization or covered stent implantation. The sentinel bleeding should be given great attention.
ObjectiveTo investigate the application of imbedding pancreaticojejunostomy in pure laparoscopic pancreaticoduodenectomy. MethodsEighty-five cases of laparoscopic pancreaticoduodenectomy in our hospital from May 2014 to December 2015 were analyzed retrospectively. According with inclusion criteria and exclusion criteria, 78 cases were investigated. They were divided into pancreatic duct-to-jejunum mucosa pancreaticojejunostomy group as controlled group (n=42) and imbedding pancreaticojejunostomy (technique of duct-to-mucosa PJ with transpancreatic interlocking mattress sutures) group as modified group (n=36). The rates of pancreatic fistula, abdominal infection/abscess, bile leakage, delayed gastric emptying, gastrointestinal/intraabdominal hemorrhage, pulmonary infection, and incision infection were investigated as well as hospital stays and pancreaticojejunostomy time in two groups were compared. ResultsThe rate of pancreatic fistula especially B to C grade pancreatic fistula in the modified group was obviously lower compared with which in the controlled group (8.3% vs. 31.0%, P < 0.05), pancreaticojejunostomy time ofmodified group was significantly shortened [(35.6±12.4) min vs. (52.8±24.6) min, P < 0.05] and total operative time also shortened [(322.4±23.6) min vs. (384.2±30.2) min, P < 0.05). There were no significant difference of the rates of abdominal infection/abscess, bile leakage, delayed gastric emptying, gastrointestinal/intraabdominal hemorrhage, pulmonary infection, ?incision infection, and hospital stays (P > 0.05)]. Conciusions The type of pancreaticojejunostomy has a significant impact on the rate of pancreatic fistula after laparoscopic pancreaticoduodenectomy. Imbedding pancreaticojejunostomy can decrease the rate of pancreatic fistula after operation, and shorten the pancreaticojejunostomy time and total operative time.
ObjectiveTo summarize the application status and prospect of laparoscopic pancreaticoduodenectomy (LPD).MethodThe relevant literatures about studies of LPD at home and abroad were reviewed.ResultsLPD was a difficult operation, mainly suitable for pancreatic head and periampullary benign and malignant tumors. With the development of laparoscopic techniques in recent years, LPD combined the superior mesenteric vein and portal vein resection and reconstruction, or combined multi-visceral resection was feasible, but the survival benefit of LPD with arterial resection and reconstruction and extended lymph node dissection remained to be discussed. At present, there was no clear requirement on the way to reconstruct the pancreatic fluid outflow tract, but the pancreaticojejunostomy for digestive tract reconstruction was chose by the most surgeons. The most studies had confirmed that LPD was minimally invasive and had a short-term prognosis that was not inferior to that of open pancreaticoduodenectomy. However, the results of large sample analysis about long-term survival rate and oncology results were lacking, so it was difficult to judge the advantages and disadvantages of long-term prognosis of the two methods.ConclusionsLPD is a safe, feasible, reasonable, and effective surgical method. With improvement of laparoscopic technology, LPD is expected to become a standard operation method for treatment of pancreatic head cancer and periampullary carcinoma, and oncology benefits of LPD will be further confirmed in future by large-sample clinical randomized control trials and studies of long-term prognosis follow-up.