Total mesopancreas excision for pancreatic head cancer: analysis of 120 cases

Objective： To evaluate the feasibility and safety of total mesopancreas excision （TMpE） in the treatment of pancreatic head cancer. Methods： The clinical and pathological data of 120 patients with pancreatic head cancer who had undergone TMpE in our center from May 2010 to January 2014 were retrospectively analyzed. Results： The mean operative time was （275.0±50.2） min and the average intra-operative blood loss was （390.0±160.5） mL. Post-operative complications were reported in 45 patients, while no peri-operative death was noted. The specimen margins were measured in three dimensions, and 86 patients （71.6%） achieved R0 resection. Conclusions： TMpE is safe and feasible for pancreatic head cancer and is particularly helpful to increase the R0 resection rate.

Preliminary Study of Oxidative Stress in Human Hepatocellular Carcinoma and Adjacent Normal Liver Tissues

OBJECTIVE The antioxidative system in human hepatocellular carcinoma was investigated. METHODS The activities of cytosolic catalase (CAT), superoxide dismu-tase, glutathione peroxidase (GSH-Px), glutathione S-tranferase and levels of reduced glutathione, total protein thiols and malondialdehyde were assayed in 10 cases of hepatocellular carcinoma and adjacent normal liver. RESULTS Hepatoma tissues showed higher activities of CAT, GSH -Px and lower content of total antioxidative capacity compared to adjacent normal liver tissue (P<0.05). CONCLUSION These findings suggest that the antioxidative defense-related enzymes and antioxidants are largely regulated in hepatoma cells. However, the mechanism which is not clear requires further investigation.

Hotspots and difficulties of biliary surgery in older patients

With the accelerated aging society in China,the incidence of biliary surgical diseases in the elderly has increased significantly.The clinical characteristics of these patients indicate that improving treatment outcomes and realizing healthy aging are worthy of attention.How to effectively improve the treatment effect of geriatric biliary surgical diseases has attracted widespread attention.This paper reviews and comments on the hotspots and difficulties of biliary surgery in older patients from six aspects:(1)higher morbidity associated with an aging society,(2)prevention and control of pre-operative risks,(3)extending the indications of laparoscopic surgery,(4)urgent standardization of minimally invasive surgery,(5)precise technological progress in hepatobiliary surgery,and(6)guarantee of peri-operative safety.It is of great significance to fully understand the focus of controversy,actively make use of its favorable factors,and effectively avoid its unfavorable factors,for further improving the therapeutic effects of geriatric biliary surgical diseases,and thus benefits the vast older patients with biliary surgical diseases.Accordingly,a historical record with the highest age of 93 years for laparoscopic transcystic common bile duct exploration has been created by us recently.

ALPPS治疗肝细胞癌10年回望:永恒的理念 慎选的术式

联合肝脏分割和门静脉结扎二步肝切除术(ALPPS)及其改进术式治疗余肝体积(FLR)不足的原发性肝细胞癌(HCC)的近10年的临床实践表明,其围手术期并发症发生率和病死率仍偏高,远期疗效改善不明显。主要原因有:患者在短期内需承受二次肝脏外科手术的打击;FLR不足的HCC多为中晚期,术后易发生复发和转移;ALPPS仅实现了外科技术上的切除,并未实现肿瘤生物学上的切除。既往研究结果证明,中晚期HCC经局部治疗实现降期后再切除,其5年生存率与早期HCC切除后相当。因此,要提高FLR不足HCC患者的远期生存率,应倡导以肿瘤生物学转化为先、FLR增生为后的双转化策略和技术。靶向、免疫治疗联合局部治疗有望大幅提高转化率。回望ALPPS治疗HCC 10年的发展历程,留下的是促使FLR快速增生的永恒理念,慎选的是高代价、高风险、远期疗效提升不理想的外科术式。

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.

Hepatopancreatoduodenectomy for advanced biliary malignancies

Background:Hepatopancreatoduodenectomy(HPD)has been considered the only curative treatment for metastatic cholangiocarcinoma and some locally advanced gallbladder cancers(GBCs).However,HPD has not yet been included in treatment guidelines as a standard surgical procedure in consideration of its morbidity and mortality rates.The aim of this study was to evaluate the safety and effectiveness of HPD in treating biliary malignancies.Methods:The medical records of 57 patients with advanced biliary cancer undergoing HPD from January 2009 to December 2019 were retrospectively retrieved.A case-control analysis was conducted at our department.Patients with advanced GBC who underwent HPD(HPD-GBC group)were compared with a control group(None-HPD-GBC group).Baseline characteristics,preoperative treatments,tumor pathologic features,operative results,and prognosis were assessed.Results:Thirteen patients with cholangiocarcinoma and 44 patients with GBC underwent HPD at our department.Significant postoperative complications(grade III or greater)and postoperative pancreatic fistula were observed in 24(42.1%)and 15(26.3%)patients,respectively.One postoperative death occurred in the present study.Overall survival(OS)was longer in patients with advanced cholangiocarcinoma than in those with GBC(median survival time[MST],31 months vs.11 months;P<0.001).In the subgroup analysis of patients with advanced GBC,multivariate analysis demonstrated that T4 stage tumors(P=0.012),N2 tumors(P=0.001),and positive margin status(P=0.004)were independently associated with poorer OS.Patients with either one or more prognostic factors exhibited a shorter MST than patients without those prognostic factors(P<0.001).Conclusion:HPD could be performed with a relatively low mortality rate and an acceptable morbidity rate in an experienced highvolume center.For patients with advanced GBC without an N2 or T4 tumor,HPD can be a preferable treatment option.

Identification of publication characteristics and research trends in the management of gallbladder cancer

Background:To date,no comprehensive analysis of gallbladder cancer(GBC)management has been reported.We aimed to identify the publication characteristics and research trends in managing GBC over the past three decades.Methods:We selected the 100 most cited articles and performed a bibliometric analysis to summarize the publication characteristics,explore research hotspots,and identify research trends in the management of GBC.Results:The total citations of the included articles ranged from 123 to 1822.Period II(2001–2010)yielded the highest number of included articles,whereas the lowest was in Period III(2011–2020).The United States and Japan published the most papers,in which the Memorial Sloan–Kettering Cancer Center and Nagoya University were the leading institutions,respectively.The most influential authors were Blumgart LH and Fong YM from the United States.Cooperation among countries,institutions,and authors was weak.The Annals of Surgery contributed the most articles with the highest number of total citations.The most researched topic was surgery,followed by systemic therapy and adjuvant therapy.Since Period I,the percentage of surgery-related publications continuously decreased(Periods II and III versus Period I,both p<0.001),with a concomitant increase in those of adjuvant therapy(Period III versus Period I,p=0.004)and systemic therapy(Period II versus Period I,p=0.004;Period III versus Period I,p=0.002).Conclusions:Surgery remains the preferred treatment,while there is a tendency toward adjuvant and systemic therapy in GBC management.An increase in local and international collaboration for managing GBC is required.