International experts consensus guidelines on robotic liver resection in 2023

The robotic liver resection(RLR)has been increasingly applied in recent years and its benefits shown in some aspects owing to the technical advancement of robotic surgical system,however,controversies still exist.Based on the foundation of the previous consensus statement,this new consensus document aimed to update clinical recommendations and provide guidance to improve the outcomes of RLR clinical practice.The guideline steering group and guideline expert group were formed by 29 international experts of liver surgery and evidence-based medicine(EBM).Relevant literature was reviewed and analyzed by the evidence evaluation group.According to the WHO Handbook for Guideline Development,the Guidance Principles of Development and Amendment of the Guidelines for Clinical Diagnosis and Treatment in China 2022,a total of 14 recommendations were generated.Among them were 8 recommendations formulated by the GRADE method,and the remaining 6 recommendations were formulated based on literature review and experts’opinion due to insufficient EBM results.This international experts consensus guideline offered guidance for the safe and effective clinical practice and the research direction of RLR in future.

Robotic versus laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: A propensity score-matched analysis

Background: Minimally invasive surgery is becoming increasingly popular in the field of pancreatic surgery. However, there are few studies of robotic distal pancreatectomy(RDP) for pancreatic ductal adenocarcinoma(PDAC). This study aimed to investigate the efficacy and feasibility of RDP for PDAC. Methods: Patients who underwent RDP or laparoscopic distal pancreatectomy(LDP) for PDAC between January 2015 and September 2020 were reviewed. Propensity score matching analyses were performed. Results: Of the 335 patients included in the study, 24 underwent RDP and 311 underwent LDP. A total of 21 RDP patients were matched 1:1 with LDP patients. RDP was associated with longer operative time(209.7 vs. 163.2 min;P = 0.003), lower open conversion rate(0% vs. 4.8%;P < 0.001), higher cost(15 722 vs. 12 699 dollars;P = 0.003), and a higher rate of achievement of an R0 resection margin(90.5% vs. 61.9%;P = 0.042). However, postoperative pancreatic fistula grade B or C showed no significant intergroup difference(9.5% vs. 9.5%). The median disease-free survival(34.5 vs. 17.3 months;P = 0.588) and overall survival(37.7 vs. 21.9 months;P = 0.171) were comparable between the groups. Conclusions: RDP is associated with longer operative time, a higher cost of surgery, and a higher likelihood of achieving R0 margins than LDP.

Finite Element Dynamics of Human Ear System Comprising Middle Ear and Cochlea in Inner Ear

A human middle ear consists of an eardrum and three ossicles which are linked by each other, and connect with the eardrum and an inner ear. The inner ear consists of a cochlea and a vestibular system. An abnormality of the human middle ear such as ossicular dislocation may cause conductive hearing loss. The conductive hearing loss is generally treated by surgery using artificial ossicles. The treatments of conductive hearing loss require a better understanding of characteristics and dynamic behaviors of the human middle ear when the sounds transmit from outer inner to inner ear. The purpose of this research is to simulate the dynamic behaviors of a human ear system comprising the middle ear and the cochlea in the inner ear using the finite element method (FEM). Firstly, the eigen-value analysis was performed to obtain the natural frequencies and vibration modes of the total ear system. Secondly, the frequency response analysis was carried out. Thirdly, the time history response analyses were performed using human voices as the external forces. In the time history response analyses, the sounds created as input sound pressures were used. Human voices, for example vowels “I”, “u” and “e” as input sound pressures were created by using the sound pressures downloaded from the opening samples of human voices as wav files in a website. Then it was clarified that the high frequency components of sounds are reduced by the middle ear system.

Preoperative serum carbohydrate antigen 19-9 levels predict early recurrence after the resection of early-stage pancreatic ductal adenocarcinoma

BACKGROUND Pancreatic ductal adenocarcinoma(PDAC)is a serious disease with a poor prognosis.Only a minority of patients undergo surgery due to the advanced stage of the disease,and patients with early-stage disease,who are expected to have a better prognosis,often experience recurrence.Thus,it is important to identify the risk factors for early recurrence and to develop an adequate treatment plan.AIM To evaluate the predictive factors associated with the early recurrence of earlystage PDAC.METHODS This study enrolled 407 patients with stage I PDAC undergoing upfront surgical resection between January 2000 and April 2016.Early recurrence was defined as a diagnosis of recurrence within 6 mo of surgery.The optimal cutoff values were determined by receiver operating characteristic(ROC)analyses.Univariate and multivariate analyses were performed to identify the risk factors for early recurrence.RESULTS Of the 407 patients,98 patients(24.1%)experienced early disease recurrence:26(26.5%)local and 72(73.5%)distant sites.In total,253(62.2%)patients received adjuvant chemotherapy.On ROC curve analysis,the optimal cutoff values for early recurrence were 70 U/mL and 2.85 cm for carbohydrate antigen 19-9(CA 19-9)levels and tumor size,respectively.Of the 181 patients with CA 19-9 level>70 U/mL,59(32.6%)had early recurrence,compared to 39(17.4%)of 226 patients with CA 19-9 level≤70 U/mL(P<0.001).Multivariate analysis revealed that CA 19-9 level>70 U/mL(P=0.006),tumor size>2.85 cm(P=0.004),poor differentiation(P=0.008),and non-adjuvant chemotherapy(P=0.025)were significant risk factors for early recurrence in early-stage PDAC.CONCLUSION Elevated CA 19-9 level(cutoff value>70 U/mL)can be a reliable predictive factor for early recurrence in early-stage PDAC.As adjuvant chemotherapy can prevent early recurrence,it should be recommended for patients susceptible to early recurrence.

边缘区淋巴瘤晚期患者R-CVP后利妥昔单抗维持治疗的Ⅱ期研究:一项改善淋巴瘤生存协会(CISL)的研究

背景与目的利妥昔单抗是一种靶向CD20的单克隆抗体,在治疗边缘区淋巴瘤(marginal zone lymphoma,MZL)中可以单药或联合化疗使用,可提高缓解率和生存率,但治疗后仍可能会复发。因此,仍需探索如何延长MZL患者的缓解期的治疗方案。这项多中心、单臂、开放标签的Ⅱ期研究评估了对一线R-CVP(rituximab,cyclophosphamide,vincristine,and prednisolone;利妥昔单抗、环磷酰胺、长春新碱和泼尼松龙)治疗有反应的Ⅲ–Ⅳ期CD20阳性MZL患者进行利妥昔单抗维持治疗2年的生存率。本研究旨在明确R-CVP后利妥昔单抗维持治疗的策略是否有进一步研究的价值。方法在利妥昔单抗维持治疗之前,Ⅲ–Ⅳ期MZL患者应接受6–8周期的R-CVP一线治疗。每个周期为3周,第1 d静脉输注利妥昔单抗(375 mg/m^2)、环磷酰胺(750 mg/m^2)和长春新碱(1.4 mg/m^2;最大2 mg),第1–5 d口服泼尼松龙(100 mg)。对R-CVP治疗达到完全缓解(complete response,CR)、部分缓解(part response,PR)或疾病稳定(stable response,SD)的患者进行利妥昔单抗维持治疗,每8周静脉注射利妥昔单抗375mg/m^2,直到12个周期。主要终点为无进展生存期(progression-free surviva,PFS),次要终点为总生存期(overall survival,OS)和治疗安全性。结果共纳入47例患者,其中45(96%)例接受了利妥昔单抗维持治疗。15(33%)例患者有淋巴结MZL。在进行R-CVP一线治疗后,分别有20(44%)例、22(49%)例和3(7%)例的患者达到了CR、PR和SD。中位随访38.2个月后,患者的3年PFS率为81%。在利妥昔单抗维持治疗期间,R-CVP治疗后有6例PR和1例SD患者获得CR。LDH升高和B症状是PFS的重要预后因素(P=0.003),3年OS率为90%。利妥昔单抗维持治疗的耐受性良好,常见的治疗性不良事件为感觉性神经病(18%)、肌痛(13%)、疲劳(9%)和中性粒细胞减少(9%)。结论一线R-CVP治疗后利妥昔单抗维持治疗在Ⅲ–Ⅳ期MZL患者中不仅表现出较好的PFS,而且药物毒性反应评价良好。

Disseminated osteomyelitis after urinary tract infection in immunocompetent adult:A case report

BACKGROUND Urinary tract infection(UTI)is one of the most common bacterial infections.Acute pyelonephritis or upper urinary tract infection is often accompanied by bacteremia;however,bacteremia resolves in most cases without complication.Rarely,complications due to bacteremia occur.One of these is osteomyelitis.It mainly affects the lumbar vertebral bodies,and rarely affects other site.CASE SUMMARY An 80-year-old woman presented to the hospital with a two-month history of pain in both legs.Two months ago,she was admitted to the hospital for fever,flank pain,and urinary frequency and was diagnosed with bacteremic UTI.During hospitalization,she complained of pain in both legs;however,the pain resolved shortly after,and no abnormalities were observed on physical examination.Therefore,she was placed on 2-wk antibiotic therapy for UTI without further evaluation for leg pain.However,pain recurred after discharge and persisted;therefore,an imaging test was performed.Bone scan and magnetic resonance imaging suggested osseous infection in both femurs,tibiae and patellae.Surgical treatment was performed,and tissue-and bone cultures revealed Escherichia coli,a previously observed pathogen,which demonstrated same antibiotic sensitivities,as noted in previous UTI.She was diagnosed with disseminated osteomyelitis,as a complication of UTI,and was placed on an 8-wk antibiotic therapy.CONCLUSION Indication for osteomyelitis should be high regardless of bone pain at sites other than lumbar spine after or during UTI.

Robotic versus laparoscopic liver resection for huge (≥10 cm) liver tumors: an international multicenter propensity-score matched cohort study of 799 cases

Background:The use of laparoscopic(LLR)and robotic liver resections(RLR)has been safely performed in many institutions for liver tumours.A large scale international multicenter study would provide stronger evidence and insight into application of these techniques for huge liver tumours≥10 cm.Methods:This was a retrospective review of 971 patients who underwent LLR and RLR for huge(≥10 cm)tumors at 42 international centers between 2002-2020.Results:One hundred RLR and 699 LLR which met study criteria were included.The comparison between the 2 approaches for patients with huge tumors were performed using 1:3 propensity-score matching(PSM)(73 vs.219).Before PSM,LLR was associated with significantly increased frequency of previous abdominal surgery,malignant pathology,liver cirrhosis and increased median blood.After PSM,RLR and LLR was associated with no significant difference in key perioperative outcomes including media operation time(242 vs.290 min,P=0.286),transfusion rate rate(19.2%vs.16.9%,P=0.652),median blood loss(200 vs.300 mL,P=0.694),open conversion rate(8.2%vs.11.0%,P=0.519),morbidity(28.8%vs.21.9%,P=0.221),major morbidity(4.1%vs.9.6%,P=0.152),mortality and postoperative length of stay(6 vs.6 days,P=0.435).Conclusions:RLR and LLR can be performed safely for selected patients with huge liver tumours with excellent outcomes.There was no significant difference in perioperative outcomes after RLR or LLR.

International expert consensus on laparoscopic pancreaticoduodenectomy

Importance:While laparoscopic pancreaticoduodenectomy(LPD)is being adopted with increasing enthusiasm worldwide,it is still challenging for both technical and anatomical reasons.Currently,there is no consensus on the technical standards for LPD.Objective:The aim of this consensus statement is to guide the continued safe progression and adoption of LPD.Evidence Review:An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy.Statements were produced upon reviewing the literature and assessed by the members of the expert panel.The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019.The Web of Science,Medline,and Cochrane Library and Clinical Trials databases were searched,The search strategy included,but was not limited to,the terms'laparoscopic','pancreaticoduodenectomy,'pancreatoduodenectomy','Whipple's operation',and'minimally invasive surgery'.Reference lists from the included articles were manually checked for any additional studies,which were included when appropriate.Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements.The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan,China.Findings:Twenty-eight international experts from 8 countries constructed the expert panel.Sixteen statements were produced by the members of the expert panel.At least 80%of responders agreed with the majority(80%)of statements.Other than three randomized controlled trials published to date,most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument.Conclusions and Relevance:The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD.LPD is currently in its development and exploration stages,as defined by the international IDEAL framework for surgical innovation.More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of;evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

Phase Ⅱ study of R-CVP followed by rituximab maintenance therapy for patients with advanced marginal zone lymphoma:consortium for improving survival of lymphoma(CISL)study

Background:The response rate and survival improvement for rituximab,a CD20-targeting monoclonal antibody,have been demonstrated in marginal zone lymphoma(MZL)as monotherapy and in combination with chemotherapeutic regimens,yet relapses still occur despite treatment completion.Thus,extending the period of remission in MZL patients remains an essential goal.This multicenter,single-arm,open-label phase II study evaluated the survival efficacy of 2 years of rituximab-maintenance therapy in patients with stage III-IV CD20-positive MZL who had responded to first-line R-CVP(rituximab,cyclophosphamide,vincristine,and prednisolone).The objective of this study was to determine whether rituximab maintenance following R-CVP warrants further investigation.Methods:Prior to rituximab-maintenance therapy,patients received 6-8 cycles of first-line R-CVP therapy for stage III-IV MZL.Rituximab(375 mg/m^(2)),cyclophosphamide(750 mg/m^(2)),and vincristine(1.4 mg/m^(2);maximum 2 mg)were administered via an intravenous infusion on day 1 of each 3-week cycle,while oral prednisolone(100 mg)was given on days 1-5 of each 3-week cycle.The patients who achieved complete response(CR),partial response(PR),or stable disease(SD)to R-CVP treatment,were prescribed rituximab-maintenance therapy which was administered intravenously at a dose of 375 mg/m^(2) every 8 weeks for up to 12 cycles.The primary endpoint was progression-free survival(PFS).Secondary endpoints were overall survival(OS)and treatment safety.Results:47 patients were enrolled,of whom,45(96%)received rituximab-maintenance treatment.Fifteen(33%)patients had nodal MZL.Following R-CVP first-line therapy,20(44%),22(49%),and 3(7%)patients achieved CR,PR,and SD,respectively.After a median follow-up of 38.2 months,their observed 3-year PFS rate was 81%.During the rituximab-maintenance,6 PR and 1 SD patients achieved CR following the administration of R-CVP.Elevated LDH and the presence of B symptoms were found to be significant prognostic factors for PFS(P=0.003)and demonstrated a 3-year OS rate of 90%.Rituximab-maintenance therapy was well tolerated,and the common treatment-emergent adverse events were sensory neuropathy(18%),myalgia(13%),fatigue(9%),and neutropenia(9%).Conclusion: Rituximab-maintenance therapy following first-line R-CVP demonstrated good PFS in patients with stage III-IV MZL, in addition to a favorable toxicity profile.

Development of oxide dispersion strengthened ferritic steels with and without aluminum

Pure Fe, Cr, AI, Ti elemental powders and prealloyed Y203 powder were processed by high energy mechanical milling. The compositions of the mixed powders are designed as Fe-18Cr-0.2Ti-0.35Y2O3 and Fe-18Cr-5Al-0.2Ti-0.35Y2O3 in weight percent. The asmilled powders were consolidated by hot extrusion at 1423 K. The dispersed oxide particles were identified to be titania ＋ yttria for Al-free oxide dispersion strengthened （ODS） steel and alumina ＋ yttria for Al-added ODS steel, respectively. The ultimate tensile strength of Al-free ODS steel was higher than that of Al-added ODS steel over the temperature range of 298-973 K, because of the difference in number density and size of thermally stable oxide particles dispersed in both steel matrices. The strength in the longitudinal direction was lower than that in the transverse direction, probably due to anisotropy of the microstructure with elongated grains in the hot-extrusion direction for the 18%Cr-ODS steels with and without 5% Al.

Minimally invasive liver resection for huge(≥10cm)tumors:an international multicenter matched cohort study with regression discontinuity analyses

Background:The application and feasibility of minimally invasive liver resection(MILR)for huge liver tumours(≥10 cm)has not been well documented.Methods:Retrospective analysis of data on 6,617 patients who had MILR for liver tumours were gathered from 21 international centers between 2009-2019.Huge tumors and large tumors were defined as tumors with a size≥10.0 cm and 3.0-9.9 cm based on histology,respectively.1:1 coarsened exact-matching(CEM)and 1:2 Mahalanobis distance-matching(MDM)was performed according to clinically-selected variables.Regression discontinuity analyses were performed as an additional line of sensitivity analysis to estimate local treatment effects at the 10-cm tumor size cutoff.Results:Of 2,890 patients with tumours≥3 cm,there were 205 huge tumors.After 1:1 CEM,174 huge tumors were matched to 174 large tumors;and after 1:2 MDM,190 huge tumours were matched to 380 large tumours.There was significantly and consistently increased intraoperative blood loss,frequency in the application of Pringle maneuver,major morbidity and postoperative stay in the huge tumour group compared to the large tumour group after both 1:1 CEM and 1:2 MDM.These findings were reinforced in RD analyses.Intraoperative blood transfusion rate and open conversion rate were significantly higher in the huge tumor group after only 1:2 MDM but not 1:1 CEM.Conclusions:MILR for huge tumours can be safely performed in expert centers It is an operation with substantial complexity and high technical requirement,with worse perioperative outcomes compared to MILR for large tumors,therefore judicious patient selection is pivotal.