The application of the extraglissonian approach for selective hepatic inflow occlusion during laparoscopic anatomical segmentectomy

Objective:Laparoscopic anatomical hepatectomy has been proven to be achievable for segmentectomy,subsegmentectomy and multi-segmentectomy.The extraglissonian approach in the context of selective hepatic inflow ocdlusion has been skilled under laparoscopy.This study aims to examine the suitability of the technique stated above for laparoscopic anatomical hepatectomy.Methods:This retrospective study analyzed the dinical data of 114 patients diagnosed with hepatocel-lular carcinoma who underwent laparoscopic anatomical hepatectomy using the extraglissonian hepatic inflow occlusion technique at the Faculty of Hepato-Pancreato-Biliary Surgery,Chinese PLA General Hospital between September 2020 and December 2022.Results:The success rate of achieving the ischemic area using the described methods was determined to be 74.6%.Out of the 85 cases that underwent laparoscopic anatomical hepatectomy,34 cases involved segmentectomy,5 cases involved subsegmentectomy,and 46 cases involved multi-segmentectomy.The average duration of the operation,blood loss volume,and postoperative hospi-tal stay were 229.0±85.0 min,133.0±112.0 mL,and 5.4±1.7 d,res pectively.Notably,no intraoperative blood transfusions were necessary,and no postoperative complications were observed.Conclusion:The extraglissonian hepatic inflow occlusion technique exhibits a notable advantage in terms of a high success rate,effectively guiding the selection process during laparoscopic parenchymal tran-section.Moreover,this technique has demonstrated safety,reproducibility,and significant potential for broader clinical adoption.

肝癌解剖性肝段切除术:从开腹到腔镜

肝癌手术切除分为解剖性和非解剖性切除(即局部切除)。解剖性肝切除是指切除肿瘤原发灶和为肿瘤供血的门静脉分支所支配的流域,可为肝段、亚肝段或联合肝段,因其符合肿瘤学和解剖学原则而具有更好的疗效[1]。目前,对于直径2~5 cm的肝癌,解剖性肝段切除为其首选的治疗方法。开腹解剖性肝段切除技术经过30余年发展已较为完善,随着腔镜技术的进步,近10年来腔镜解剖性肝段切除技术也日趋成熟。解放军总医院率先在国内开展开腹解剖性肝段切除和腔镜肝切除,近些年来积极探索腔镜下的解剖性肝段切除。笔者在此对其进行简要论述。

Guidelines for the diagnosis and treatment of acute pancreatitis in China (2021)

Acute pancreatitis(AP)is a common acute abdominal condition of the digestive system.In recent years,treatment concepts,methods,and strategies for the diagnosis of AP have advanced,and this has played an important role in promoting the standardization of AP diagnosis and treatment and improving the treatment quality of AP patients.On the basis of previous guidelines and expert consensus,this guideline adopts an evidence-based,problem-based expression;synthesizes important clinical research data at home and abroad in the most recent 5 years;and forms 29 recommendations through multidisciplinary expert discussion,including diagnosis,treatment,and follow-up.It is expected to provide evidence support for the treatment of AP in the clinical setting in China.

The current surgical treatment of pancreatic neuroendocrine neoplasms in China: a national wide cross-sectional study

Objective:The aim of this study is to investigate the current status of the diagnosis and treatment of patients with pancreatic neuroendocrine neoplasms(pNENs)undergoing surgery in China.Methods:This is a multicenter cross-sectional study performed in China.Data from patients with pNENs undergoing surgery at 33 high-volume medical centers,where the number of pancreatectomies exceeds 20 cases per year,were collected and analyzed between March 1,2016 and February 28,2017.Results:In total,392 patients with pNENs were enrolled.The male to female ratio was 1.4.The majority of patients were aged between 40 and 70 years.65.6%of the patients had non-functional tumors.Among those with functional tumors,the percentages of insulinomas,gastrinomas,glucagonomas,and vasoactive intestinal peptide-secreting tumors were 94.8%,1.5%,2.2%,and 1.5%,respectively.Multidisciplinary team(MDT)discussion was conducted for 39.0%of the patients.Minimally invasive surgery was performed on 31.1%of the 392 patients.The incidence of grade B/C pancreatic fistula formation was 4.4%.A total of 89.0%of the surgeries achieved R0 resection,and 41.6%of the tumors were well differentiated.Lymph node metastasis was present in 8.9%of the patients.The percentages of patients with grades G1,G2,and G3 disease were 49.2%,45.7%,and 5.1%,respectively.Conclusion:This multicenter cross-sectional study systematically presents the current status of the diagnosis and treatment of patients with pNENs undergoing surgery in China.MDT consultation for pNENs has not been widely implemented in China.Although the incidence of surgical complications is relatively low,minimally invasive procedures should be further promoted.This study shows us how to improve the outcomes of these patients.

Guidelines for the diagnosis and treatment of pancreatic cancer in China (2021)

The incidence of pancreatic cancer has been rising worldwide,and its clinical diagnosis and treatment remain a great challenge.To present the update and improvements in the clinical diagnosis and treatment of pancreatic cancer in recent years,Chinese Pancreatic Association,the Chinese Society of Surgery,Chinese Medical Association revised the Guidelines for the Diagnosis and Treatment of Pancreatic Cancer in China(2014)after reviewing evidence-based and problem-oriented literature published during 2015-2021,mainly focusing on highlight issues regarding diagnosis and surgical treatment of pancreatic cancer,conversion strategies for locally advanced pancreatic cancer,treatment of pancreatic cancer with oligo metastasis,adjuvant and neoadjuvant therapy,standardized processing of surgical specimens and evaluation of surgical margin status,systemic treatment for unresectable pancreatic cancer,genetic testing,as well as postoperative follow up of patients with pancreatic cancer.Forty recommendation items were finally proposed based on the above issues,and the quality of evidence and strength of recommendations were graded using the Grades of Recommendation,Assessment,Development,and Evaluation system.This guideline aims to standardize the clinical diagnosis and therapy,especially surgical treatment of pancreatic cancer in China,and further improve the prognosis of patients with pancreatic cancer.

Correlative factor of death in patients with infected pancreatic necrosis after surgical intervention

Background:Acute pancreatitis(AP)was a potentially fatal disease with a variation in severity.Infected pancreatic necrosis was a common complication in AP which needed surgical intervention.The present study was to study the correlative factors of death in patients with infected pancreatic necrosis after surgical intervention.Methods:From January 2016 to October 2019,a total of 186 patients with infected pancreatic necrosis after surgical intervention in the First Medical Center,Chinese PLA General Hospital were retrospectively enrolled in this study.Of the 186 patients,22 who died in the hospital were defined as a mortality group and the others as a survival group.The clinical characteristic of the 2 groups was compared and the relative risk of mortality in patients with infected pancreatic necrosis after the surgical intervention was studied.Results:Acute fluid collection,acute kidney injury,acute lung injury,acute liver injury,multiple organ dysfunction syndromes,abdominal bleeding,abdominal Acinetobacter baumannii infection,pulmonary infection,pulmonary A baumannii infection,positive blood culture,A baumannii of blood culture,severe acute pancreatitis according to Atlanta 2012,the use of continuous renal replacement therapy,mechanical ventilation and minimally invasive retroperitoneal pancreatic necrosectomy was associated with death in hospital.Older age,longer acute kidney injury lasting time,longer acute lung injury lasting time,longer acute liver injury lasting time,and longer multiple organ dysfunction syndromes lasting time in predicting mortality in patients with infected pancreatic necrosis after surgical intervention were(0.635[95%confidence interval(CI):0.512-0.758],P=.040),(0.877[95%CI:0.788-0.965],P=.000),(0.932[95%CI:0.897-0.968],P=.000),(0.822[95%CI:0.708-0.935],P=.000),and(0.943[95%CI:0.887-0.998],P=.000).Due to the small number of death cases,the results of the multivariate analyses were not available.Conclusion:In this single-center retrospective study of 186 cases of infected pancreas necrosis,the correlative factors of death are identified.The results warranted further strategies are needed especially focusing on elder patients to prevent blood infection and to protect the functions of vital organs.

Clinical application of trans-sinus gastric stent placement and drainage in the management of persistent external pancreatic fistula after minimal access retroperitoneal pancreatic necrosectomy in severe acute pancreatitis patients

Background:Persistent external pancreatic fistula(EPF)in patients with pancreatic duct disruption or disconnection can result from minimal access to retroperitoneal pancreatic necrosectomy(MARPN)in severe acute pancreatitis patients,which is a difficult problem for clinicians and requires a long treatment duration.This study aimed to investigate the effectiveness and safety of trans-sinus gastric stent placement and drainage using interventional technology in the management of persistent EPF after MARPN in severe acute pancreatitis.Methods:From August 2018 to December 2020,the data of 9 patients with persistent EPF treated with trans-sinus gastric stent placement and drainage in our hospital were retrospectively collected.The main outcome measures were technical success rate,recurrence rate,new pancreatic fluid collection,morbidity,and mortality.All patients were followed up after the procedure through clinic visits and imaging modalities.Results:The median age of the patients was 46 years(30-61 years).The median persistent EPF duration was 5 months(2-12 months).The median follow-up time was 41 months(range,20-47 months).The median operation time was 48 minutes(range,40-54 minutes),and the technical success rate was 100%.Seven days after treatment,the percutaneous drainage tubes of all patients were removed.Six months after the procedure,2 patients lost the stents,and one of those patients suffered from a pseudocyst,which gradually increased to a maximum diameter of 7 cm over 9 months.Therefore,a double pigtail drainage tube was placed under the guidance of an endoscope.The second of these 2 patients had no recurrence or pseudocyst.Twelve months after the procedure,another 3 patients lost the stents;18 months after the procedure,another 2 patients lost the stents.These patients had no recurrence as well.No other adverse events or deaths occurred during the study period.Conclusion:Trans-sinus tract gastric stent placement and drainage are safe and effective in the treatment of persistent EPF after MARPN in severe acute pancreatitis patients.However,this study had a small sample size and did not include a comparative group.