Perineural invasion of hilar cholangiocarcinoma in Chinese population: One center’s experience

BACKGROUND Hilar cholangiocarcinoma(HCCA)often produces perineural invasion(PNI)extending to extra-biliary sites,while significant confusion in the incidence of PNI in HCCA has occurred in the literature,and the mechanism of that procedure remains unclear.AIM To summarize the incidence of PNI in HCCA and to provide the distribution of nerve plexuses around hepatic portal to clinical surgeons.METHODS Reported series with PNI in HCCA since 1996 were reviewed.A clinicopathological study was conducted on sections from 75 patients with HCCA to summarize the incidence and modes of PNI.Immunohistochemical stains for CD34 and D2-40 in the cancer tissue were performed to clarify the association of PNI with microvessel and lymph duct.Sections of the hepatoduodenal ligament from autopsy cases were scanned and handled by computer to display the distribution of nerve plexuses around the hepatic portal.RESULTS The overall incidence of PNI in this study was 92%(69 of 75 patients),while the rate of PNI in HCCA in the literature ranging from 38%to 100%.The incidence of PNI did not show any remarkable differences among various differentiated groups and Bismuth-Corlette classification groups.Logistic regression analysis identified the depth of tumor invasion was the only factor that correlated significantly with PNI(P<0.01).In spite of finding tumor cells that could invade microvessels and lymph ducts in HCCA,we did not find tumor cells invaded nerves via microvessels or lymph ducts.Three nerve plexuses in the hepatoduodenal ligament and Glisson’s sheath were classified,and they all surrounded the great vessels very closely.CONCLUSION The incidence of PNI of HCCA in Chinese population is around 92%and correlated significantly with a depth of tumor invasion.It also should be considered when stratifying HCCA patients for further treatment.

Radioactive ^125I seed implantation for locally advanced pancreatic cancer:A retrospective analysis of 50 cases

BACKGROUND Pancreatic cancer is one of the common malignant tumors of the digestive system,and radical resection is the first choice of treatment for pancreatic cancer.If patients with locally advanced pancreatic cancer cannot be treated in time and effectively,their disease often develops rapidly and their survival period is very short.AIM To evaluate the therapeutic effect of ^125I seed implantation in patients with locally advanced pancreatic cancer.METHODS The demographics and perioperative outcomes of a consecutive series of patients who underwent ^125I seed implantation to treat locally advanced pancreatic cancer between January 1,2017 and June 30,2019 were retrospectively analyzed.According to the results of preoperative computed tomography or magnetic resonance imaging,the treatment planning system was used to determine the area and number of ^125I seeds implanted.During the operation,^125I seeds were implanted into the tumor under the guidance of intraoperative ultrasound,with a spacing of 1.5 cm and a row spacing of 1.5 cm.For patients with obstructive jaundice and digestive tract obstruction,choledochojejunostomy and gastroenterostomy were performed simultaneously.After operation,the patients were divided into a non-chemotherapy group and a chemotherapy group that received gemcitabine combined with albumin-bound paclitaxel treatment.RESULTS Among the 50 patients,there were 29 males and 21 females,with a mean age of 56.9±9.8 years.The main reason for the failure of radical resection was superior mesenteric artery invasion(37,74%),followed by superior mesenteric vein invasion(33,66%).Twenty-one(62%)patients underwent palliative surgery and postoperative pain relief occurred in 40(80%)patients.The estimated blood loss in operation was 107.4±115.3 mL and none of the patient received blood transfusion.The postoperative hospital stay was 7.5±4.2 d;one patient had biliary fistula and three had pancreatic fistula,all of whom recovered after conservative treatment.After operation,26 patients received chemotherapy and 24 did not.The 1-year survival rate was significantly higher in patients who received chemotherapy than in those who did not(60.7%vs 35.9%,P=0.034).The mean overall survival of patients of the chemotherapy group and nonchemotherapy group was 14 and 11 mo,respectively(χ^2=3.970,P=0.046).CONCLUSION Radioactive ^125I seed implantation combined with postoperative chemotherapy can prolong the survival time,relieve pain,and improve the quality of life of patients with locally advanced pancreatic cancer.

Radiomics and nomogram of magnetic resonance imaging for preoperative prediction of microvascular invasion in small hepatocellular carcinoma

BACKGROUND Microvascular invasion(MVI)of small hepatocellular carcinoma(sHCC)(≤3.0 cm)is an independent prognostic factor for poor progression-free and overall survival.Radiomics can help extract imaging information associated with tumor pathophysiology.AIM To develop and validate radiomics scores and a nomogram of gadolinium ethoxybenzyl-diethylenetriamine pentaacetic acid(Gd-EOB-DTPA)-enhanced magnetic resonance imaging(MRI)for preoperative prediction of MVI in sHCC.METHODS In total,415 patients were diagnosed with sHCC by postoperative pathology.A total of 221 patients were retrospectively included from our hospital.In addition,we recruited 94 and 100 participants as independent external validation sets from two other hospitals.Radiomics models of Gd-EOB-DTPA-enhanced MRI and diffusion-weighted imaging(DWI)were constructed and validated using machine learning.As presented in the radiomics nomogram,a prediction model was developed using multivariable logistic regression analysis,which included radiomics scores,radiologic features,and clinical features,such as the alpha-fetoprotein(AFP)level.The calibration,decision-making curve,and clinical usefulness of the radiomics nomogram were analyzed.The radiomic nomogram was validated using independent external cohort data.The areas under the receiver operating curve(AUC)were used to assess the predictive capability.RESULTS Pathological examination confirmed MVI in 64(28.9%),22(23.4%),and 16(16.0%)of the 221,94,and 100 patients,respectively.AFP,tumor size,non-smooth tumor margin,incomplete capsule,and peritumoral hypointensity in hepatobiliary phase(HBP)images had poor diagnostic value for MVI of sHCC.Quantitative radiomic features(1409)of MRI scans)were extracted.The classifier of logistic regression(LR)was the best machine learning method,and the radiomics scores of HBP and DWI had great diagnostic efficiency for the prediction of MVI in both the testing set(hospital A)and validation set(hospital B,C).The AUC of HBP was 0.979,0.970,and 0.803,respectively,and the AUC of DWI was 0.971,0.816,and 0.801(P<0.05),respectively.Good calibration and discrimination of the radiomics and clinical combined nomogram model were exhibited in the testing and two external validation cohorts(C-index of HBP and DWI were 0.971,0.912,0.808,and 0.970,0.843,0.869,respectively).The clinical usefulness of the nomogram was further confirmed using decision curve analysis.CONCLUSION AFP and conventional Gd-EOB-DTPA-enhanced MRI features have poor diagnostic accuracies for MVI in patients with sHCC.Machine learning with an LR classifier yielded the best radiomics score for HBP and DWI.The radiomics nomogram developed as a noninvasive preoperative prediction method showed favorable predictive accuracy for evaluating MVI in sHCC.

Robotic resection of liver focal nodal hyperplasia guided by indocyanine green fluorescence imaging: A preliminary analysis of 23 cases

BACKGROUND Focal nodal hyperplasia(FNH)is a common benign tumor of the liver.It occurs mostly in people aged 40-50 years and 90%of the patients are female.FNH can be cured by local resection.How to locate and judge the tumor boundary in real time is often a challenge for surgeons.AIM To summarize the technique and feasibility of robotic resection of FNH guided by indocyanine green(ICG)fluorescence imaging.METHODS The demographics and perioperative outcomes of a consecutive series of patients who underwent robotic resection of liver FNH guided by ICG fluorescence imaging between May 1,2018 and September 30,2019 were retrospectively analyzed.ICG was injected through the median elbow vein in all the patients at a dose of 0.25 mg/kg 48 h before the operation.During the operation,the position of FNH in the liver was located in the fluorescence mode of the Da Vinci Si robot operating system and the tumor boundary was determined during the resection.RESULTS Among the 23 patients,there were 11 males and 12 females,with a mean age of 30.5±9.3 years.Twenty-two cases completed robotic resection,while one(4.3%)case converted to open surgery.In the robotic surgery group,the operation time was 35-340 min with a median of 120 min,the intraoperative bleeding was 10-800 m L with a median of 50 m L,and the postoperative hospital stay was 1-7 d with a median of 4 d.Biliary fistula occurred in two(8.7%)patients after robotic operation and they both recovered after conservative treatment.One(4.3%)patient received blood transfusion and there was no death in this study.The postoperative hospital stay in the small tumor group was significantly shorter than that in the large tumor group(P<0.05).CONCLUSION ICG fluorescence imaging can guide the surgeon to perform robotic resection of liver FNH by locating the tumor and displaying the tumor boundary in real time.It is a safe and feasible method to ensure the complete resection of the tumor.

Radioactive 125I seed implantation for pancreatic cancer with unexpected liver metastasis:A preliminary experience with 26 patients

BACKGROUND Preoperative diagnosis rate of pancreatic cancer has increased year by year.The prognosis of pancreatic cancer patients with unexpected liver metastasis found by intraoperative exploration is very poor,and there is no effective and unified treatment strategy.AIM To evaluate the therapeutic effect of radioactive 125I seed implantation for pancreatic cancer patients with unexpected liver metastasis.METHODS The demographics and perioperative outcomes of patients who underwent 125I seed implantation to treat pancreatic cancer with unexpected liver metastasis between January 1,2017 and June 1,2019 were retrospectively analyzed.During the operation,125I seeds were implanted into the pancreatic tumor under the guidance of intraoperative ultrasound,with a spacing of 1.5 cm and a row spacing of 1.5 cm.For patients with obstructive jaundice and digestive tract obstruction,choledochojejunostomy and gastroenterostomy were performed simultaneously.After operation,the patients were divided into a non-chemotherapy group and a chemotherapy group that received gemcitabine combined with albumin-bound paclitaxel treatment.RESULTS Preoperative imaging evaluation of all patients in this study showed that the tumor was resectable without liver metastasis.There were 26 patients in this study,including 18 males and 8 females,aged 60.5±9.7 years.The most common tumor site was the pancreatic head(17,65.4%),followed by the pancreatic neck and body(6,23.2%)and pancreatic tail(3,11.4%).Fourteen patients(53.8%)underwent palliative surgery and postoperative pain relief occurred in 22 patients(84.6%).The estimated blood loss in operation was 148.3±282.1 mL and one patient received blood transfusion.The postoperative hospital stay was 7.6±2.8 d.One patient had biliary fistula,one had pancreatic fistula,and all recovered after conservative treatment.After operation,7 patients received chemotherapy and 19 did not.The 1-year survival rate was significantly higher in patients who received chemotherapy than in those who did not(68.6%vs 15.8%,P=0.012).The mean overall survival of patients in the chemotherapy group and non-chemotherapy group was 16.3 mo and 10 mo,respectively(χ2=7.083,P=0.008).CONCLUSION Radioactive 125I seed implantation combined with postoperative chemotherapy can prolong the survival time and relieve pain of pancreatic cancer patients with unexpected liver metastasis.

Robotic resection of duodenal gastrointestinal stromal tumour:Preliminary experience from a single centre

BACKGROUND Experience in minimally invasive surgery in the treatment of duodenal gastrointestinal stromal tumors(DGISTs)is accumulating,but there is no consensus on the choice of surgical method.AIM To summarize the technique and feasibility of robotic resection of DGISTs.METHODS The perioperative and demographic outcomes of a consecutive series of patients who underwent robotic resection and open resection of DGISTs between May 1,2010 and May 1,2020 were retrospectively analyzed.The patients were divided into the open surgery group and the robotic surgery group.Pancreatoduodenectomy(PD)or limited resection was performed based on the location of the tumour and the distance between the tumour and duodenal papilla.Age,sex,tumour location,tumour size,operation time(OT),estimated blood loss(EBL),postoperative hospital stay(PHS),tumour mitosis,postoperative risk classification,postoperative recurrence and recurrence-free survival were compared between the two groups.RESULTS Of the 28 patients included,19 were male and 9 were female aged 51.3±13.1 years.Limited resection was performed in 17 patients,and PD was performed in 11 patients.Eleven patients underwent open surgery,and 17 patients underwent robotic surgery.Two patients in the robotic surgery group underwent conversion to open surgery.All the tumours were R0 resected,and there was no significant difference in age,sex,tumour size,operation mode,PHS,tumour mitosis,incidence of postoperative complications,risk classification,postoperative targeted drug therapy or postoperative recurrence between the two groups(P>0.05).OT and EBL in the robotic group were significantly different to those in the open surgery group(P<0.05).All the patients survived during the follow-up period,and 4 patients had recurrence and metastasis.No significant difference in recurrence-free survival was noted between the open surgery group and the robotic surgery group(P>0.05).CONCLUSION Robotic resection is safe and feasible for patients with DGISTs,and its therapeutic effect is equivalent to open surgery.

Impact of resection margins on long-term survival after pancreaticoduodenectomy for pancreatic head carcinoma

BACKGROUND The impact of resection margin status on long-term survival after pancreaticoduodenectomy(PD) for patients with pancreatic head carcinoma remains controversial and depends on the method used in the histopathological study of the resected specimens. This study aimed to examine the impact of resection margin status on the long-term overall survival of patients with pancreatic head carcinoma after PD using the tumor node metastasis standard.METHODS Consecutive patients with pancreatic head carcinoma who underwent PD at the Chinese People's Liberation Army General Hospital between May 2010 and May 2016 were included. The impact of resection margin status on long-term survival was retrospectively analyzed.RESULTS Among the 124 patients, R0 resection was achieved in 85 patients(68.5%), R1 resection in 38 patients(30.7%) and R2 resection in 1 patient(0.8%). The 1-and 3-year overall survival(OS) rates were significantly higher for the patients who underwent R0 resection than the rates for those who underwent R1 resection(1-year OS rates: 69.4% vs 53.0%;3-year OS rates: 26.9% vs 11.7%). Multivariate analysis showed that resection margin status and venous invasion were significant risk factors for OS.CONCLUSION Resection margin was an independent risk factor for OS for patients with pancreatic head carcinoma after PD. R0 resection was associated with significantly better OS after surgery.

Early prophylactic anticoagulation with heparin alleviates mortality in critically ill patients with sepsis:a retrospective analysis from the MIMIC-IV database

Background:Minimal data exist on anticoagulation use and timing and the dose of heparin in patients with sepsis,and whether heparin use improves sepsis survival remains largely unclear.This study was performed to assess whether heparin administration would provide a survival advantage in critically ill patients with sepsis.Methods:A retrospective cohort study of patients with sepsis in the Medical Information Mart for Intensive Care(MIMIC)-IV database was conducted.Cox proportional hazards model and propensity score matching(PSM)were used to evaluate the outcomes of prophylactic anticoagulation with heparin administered by subcutaneous injection within 48 h of intensive care unit(ICU)admission.The primary outcome was in-hospital mortality.Secondary outcomes included 60-day mortality,length of ICU stay,length of hospital stay and incidence of acute kidney injury(AKI)on day 7.EValue analysis were used for unmeasured confounding.Results:A total of 6646 adult septic patients were included and divided into an early prophylactic heparin group(n=3211)and a nonheparin group(n=3435).In-hospital mortality in the heparin therapy group was significantly lower than that in the nonheparin group(prematched 14.7 vs 20.0%,hazard ratio(HR)0.77,95%confidence interval(CI)[0.68-0.87],p<0.001,and postmatched 14.9 vs 18.3%,HR 0.78,95%CI[0.68-0.89],p<0.001).Secondary endpoints,including 60-day mortality and length of ICU stay,differed between the heparin and nonheparin groups(p<0.01).Early prophylactic heparin administration was associated with in-hospital mortality among septic patients in different adjusted covariates(HR 0.71-0.78,p<0.001),and only administration of five doses of heparin was associated with decreased in-hospital mortality after PSM(HR 0.70,95%CI 0.56-0.87,p<0.001).Subgroup analysis showed that heparin use was significantly associated with reduced in-hospital mortality in patients with sepsis-induced coagulopathy,septic shock,sequential organ failure assessment score≥10,AKI,mechanical ventilation,gram-positive bacterial infection and gram-negative bacterial infection,with HRs of 0.74,0.70,0.58,0.74,0.73,0.64 and 0.72,respectively(p<0.001).E-Value analysis suggested robustness to unmeasured confounding.Conclusions:This study found an association between early administration prophylactic heparin provided to patients with sepsis and reduced risk-adjusted mortality.A prospective randomizedcontrolled study should be designed to further assess the relevant findings.