Risk scoring system and predictor for clinically relevant pancreatic fistula after pancreaticoduodenectomy

AIM: To establish a scoring system to predict clinicallyrelevant postoperative pancreatic fistula(CR-POPF)after pancreaticoduodenectomy(PD).METHODS: The clinical records of 921 consecutive patients who underwent PD between 2008 and 2013 were reviewed retrospectively. Postoperative pancreatic fistula(POPF) was defined and classified by the international study group of pancreatic fistula(ISGPF).We used a logistic regression model to determine the independent risk factors of CR-POPF and developed a scoring system based on the regression coefficient of the logistic regression model. The optimal cut-off value to divide the risk strata was determined by the Youden index. The patients were divided into two groups(low risk and high risk). The independent sample t test was used to detect differences in the means of drain amylase on postoperative day(POD) 1, 2 and 3. The optimal cut-off level of the drain amylase to distinguish CR-POPF from non-clinical POPF in the two risk strata groups was determined using the receiver operating characteristic(ROC) curves.RESULTS: Grade A POPF occurred in 106(11.5%)patients, grade B occurred in 57(6.2%) patients,and grade C occurred in 32(3.5%) patients. A predictive scoring system for CR-POPF(0-6 points) was constructed using the following four factors: 1 point for each body mass index ≥ 28 [odds ratio(OR) = 3.86;95% confidence interval(CI): 1.92-7.75, P = 0.00],soft gland texture(OR = 4.50; 95%CI, 2.53-7.98, P =0.00), and the difference between the blood loss and transfusion in operation ≥ 800 mL(OR = 3.45; 95%CI,1.92-7.75, P = 0.00); and from 0 points for a 5 mm or greater duct diameter to 3 points for a less than 2 mm duct(OR = 8.97; 95%CI: 3.70-21.77, P = 0.00). The ROC curve showed that the area under the curve of this score was 0.812. A score of 3 points was suggested to be the best cut-off value(Youden index = 0.485). In the low risk group, a drain amylase level ≥ 3600 U/L on POD3 could distinguish CR-POPF from non-clinicalPOPF(the sensitivity and specificity were 75% and85%, respectively). In the high risk group, the best cutoff was a drain amylase level of 1600(the sensitivity and specificity were 77 and 63%, respectively).CONCLUSION: A 6-point scoring system accurately predicted the occurrence of CR-POPF. In addition, a drain amylase level on POD3 might be a predictor of this complication.

Poor prognosis for hepatocellular carcinoma with transarterial chemoembolization pre-transplantation:Retrospective analysis

AIM: To investigate whether transarterial chemoembolization(TACE) before liver transplantation(LT) improves long-term survival in hepatocellular carcinoma(HCC) patients.METHODS: A retrospective study was conducted among 204 patients with HCC who received LT from January 2002 to December 2010 in PLA General Hospital. Among them, 88 patients received TACE before LT. Prognostic factors of serum α-fetoprotein(AFP), intraoperative blood loss, intraoperative blood transfusion, disease-free survival time, survival time with tumor, number of tumor nodules, tumor size, tumor number, presence of blood vessels and bile duct invasion, lymph node metastasis, degree of tumor differentiation, and preoperative liver function were determined in accordance with the Child-TurcottePugh(Child) classification and model for end-stage liver disease. We also determined time of TACE before transplant surgery and tumor recurrence and metastasis according to different organs. Cumulative survival rate and disease-free survival rate curves were prepared using the Kaplan-Meier method, and the logrank and χ2 tests were used for comparisons.RESULTS: In patients with and without TACE before LT, the 1, 3 and 5-year cumulative survival rate was 70.5% ± 4.9% vs 91.4% ± 2.6%, 53.3% ± 6.0% vs 83.1% ± 3.9%, and 46.2% ± 7.0% vs 80.8% ± 4.5%, respectively. The median survival time of patients with and without TACE was 51.857 ± 5.042 mo vs 80.930 ± 3.308 mo(χ2 = 22.547, P < 0.001, P < 0.05). The 1, 3 and 5-year disease-free survival rates for patients with and without TACE before LT were 62.3% ± 5.2% vs98.9% ± 3.0%, 48.7% ± 6.7% vs 82.1% ± 4.1%, and 48.7% ± 6.7% vs 82.1% ± 4.1%, respectively. The median survival time of patients with and without TACE before LT was 50.386 ± 4.901 mo vs 80.281 ± 3.216 mo(χ2 = 22.063, P < 0.001, P < 0.05). TACE before LT can easily lead to pulmonary or distant metastasis of the primary tumor. Although there was no significant difference between the two groups, the chance of metastasis of the primary tumor in the group with TACE was significantly higher than that of the group without TACE.CONCLUSION: TACE pre-LT for HCC patients increased the chances of pulmonary or distant metastasis of the primary tumor, thus reducing the long-term survival rate.

Endocan-expressing microvessel density as a prognostic factor for survival in human gastric cancer

AIM: To investigate the expression of endocan in tumour vessels and the relationships between endocan and the expression of vascular endothelial growth factor(VEGF) and prognosis in gastric cancer.METHODS: This study included 142 patients with confirmed gastric cancer in a single cancer centre between 2008 and 2009. Clinicopathologic features were determined, and an immunohistochemical analysis of endocan-expressing microvessel density(MVD)(endocan-MVD), VEGF and vascular endothelial growth factor receptor 2(VEGFR2) was performed. Potential relationships between endocan-MVD and clinicopathological variables were assessed using a Student's t-test or an analysis of variance test. Spearman's rank correlation was applied to evaluate the relationship between endocan-MVD and the expression of VEGF/VEGFR2. long-term survival of these patients was analysed using univariate and multivariate analyses.RESULTS: Positive staining of endocan was observed in most of the gastric cancer tissues(108/142) and in fewer of the normal gastric tissues. Endocan-MVD was not associated with gender or histological type(P > 0.05), while endocan-MVD was associated with tumour size,Borrmann type, tumour differentiation, tumour invasion, lymph node metastasis and TNM stage(P < 0.05). According to the Spearman's rank correlation analysis, endocan-MVD had a positive correlation with VEGF(r = 0.167, P = 0.047) and VEGFR2(r = 0.410, P = 0.000). The univariate analysis with a log-rank test indicated that the patients with a high level of endocan-MVD had a significantly poorer overall survival rate than those with a low level of endocan-MVD(17.9% vs 64.0%, P = 0.000). The multivariate analysis showed that a high level of endocan-MVD was a valuable prognostic factor.CONCLUSION: Endocan-MVD significantly correlates with the expression of VEGF and VEGFR2 and is a valuable prognostic factor for survival in human gastric cancer.

Robot-assisted gallbladder-preserving hepatectomy for treating S5 hepatoblastoma in a child: A case report and review of the literature

BACKGROUND Hepatoblastoma(HB) is the most common hepatic malignant tumour in children,accounting for approximately 50%-60% of primary hepatic malignant tumours in children, mostly in children under 3 years old. In Western countries, the incidence of hepatoblastoma is approximately 1-2/100000. Da Vinci surgical system is fast becoming a key instrument in microinvasive surgery. The past decade has seen the rapid development of robot-assisted laparoscopy, which expends many fields including the liver surgery. This paper discusses the significance and feasibility of robot-assisted gallbladder-preserving hepatectomy for treating S5 hepatoblastoma in children. The aim of this essay is to compare the safety and effectiveness of robotic surgery with conventional laparoscopic surgery, and explore the meaning of preservation of the gallbladder by sharing this case.CASE SUMMARY A 3-year-old child with a liver mass in the 5 th segment was treated using the Da Vinci surgical system, and the gallbladder was retained. The child was admitted to the hospital for 20 d for the discovery of the right hepatic lobe mass.Ultrasonography revealed a low echo mass, 46 mm × 26 mm × 58 mm in size,indicating hepatoblastoma in the right lobe, and enhanced computed tomography showed continuous enhancement of iso-low-density lesions with different sizes and nodules and unclear boundaries, without the dilation of the intrahepatic bile duct, no enlargement of the gallbladder, and uniform thickness of the wall. The diagnosis was "liver mass, hepatoblastoma". It was decided to perform S5 liver tumour resection. During surgery, the tumour and gallbladder were isolated first, and the gallbladder could be completely separated from the tumour surface without obvious infiltration; therefore, the gallbladder was preserved. The cutting line was marked with an electric hook. The hepatic duodenal ligament was blocked with a urethral catheter using the Pringle method, and the tumour and part of the normal liver tissue were completely resected with an ultrasound knife along the incision. The hepatic portal interdiction time was approximately 25 min. An abdominal drainage tube was inserted. The auxiliary hole was connected to the lens, and the specimen was removed. The patient's status was uneventful, and the operation time was 166 min. The robotic time was 115 min, and the bleeding amount was approximately 200 mL. In total, 300 mL of red blood cell suspension and 200 mL of plasma were injected. No serious complications occurred. Pathological findings confirmed fetal hepatoblastoma and R0 resection. A gallbladder contraction test was performed two weeks after surgery.CONCLUSION Robot-assisted S5 hepatectomy with gallbladder preservation is safe and feasible for specific patients.

Pancreaticoduodenectomy for duodenal papilla carcinoma: A single-centre 9-year retrospective study of 112 patients with long-term follow-up

AIM To retrospectively evaluate the factors that influence long-term outcomes of duodenal papilla carcinoma (DPC) after standard pancreaticoduodenectomy (SPD). METHODS This is a single-centre, retrospective study including 112 DPC patients who had a SPD between 2006 and 2015. Associations between serum levels of CA19-9 and CEA and various clinical characteristics of 112 patients with DPC were evaluated by the. 2 test and Fisher's exact test. The patients were followed-up every 3 mo in the first two years and at least every 6 mo afterwards, with a median follow-up of 60 mo (ranging from 4 mo to 168 mo). Survival analysis was conducted using the Kaplan-Meier survival and Cox proportional hazards model analysis. The difference in survival curves was evaluated with a log-rank test. RESULTS In 112 patients undergoing SPD, serum levels of CA19-9 was associated with serum levels of CEA and drainage mode (the P values were 0.000 and 0.033, respectively); While serum levels of CEA was associated with serum levels of CA19-9 and differentiation of the tumour (the P values were 0.000 and 0.033, respectively). The serum levels of CA19-9 and CEA were closely correlated (chi(2) = 13.277, r = 0.344, P = 0.000). The overall 5-year survival was 50.00% for 112 patients undergoing SPD. The Kaplan-Meier survival analysis showed that increased serum levels of CA19-9, CEA, and total bilirubin were correlated with a poor prognosis, as well as a senior grade of infiltration depth, lymph node metastases, and TNM stage(the P values were 0.033, 0.018, 0.015, 0.000, 0.000 and 0.000, respectively). Only the senior grade of infiltration depth and TNM stage retained their significance when adjustments were made for other known prognostic factors in Cox multivariate analysis (RR = 2.211, P = 0.022 and RR = 2.109, P = 0.047). CONCLUSION For patients with DPC, the serum levels of CA19-9 and CEA were closely correlated, and play an important role in poor survival. Increased serum levels of total bilirubin and lymph node metastases were also correlated with a poor prognosis. The senior grade of infiltration depth and TNM stage can serve as independent prognosis indexes in the evaluation of patients with DPC after SPD.

Robotic-assisted surgery for pediatric choledochal cyst: Case report and literature review

Our paper describes the key surgical points of pediatric choledochocystectomy performed completely by Da Vinci robotic system. A choledochocystectomy was safely carried out for a girl at our hospital, and without any complication. Then systematic literature review was done to discuss the methods of intestine surgery and intestinal anastomosis, the use of 3 rd robotic arm, the surgical safety and advantages comparing open and laparoscopic surgery. We systematically reviewed choledochocystectomy for children performed by robotic surgery. We included a total of eight domestic and foreign reports and included a total of 86 patients, whose average age was 6.3(0.3-15.9) years; the maleto-female ratio was 1:3.5(19:67). Seven patients experienced conversion to open surgery, and the surgery success rate was 91.9%(79/86). The average total operation time was 426(180-520) min, the operation time on the machine was 302(120-418) min, 11 cases used the number 3 arm, and the remaining mainly used the hitch-stitch technique to suspend the stomach wall and liver. Forty-seven patients underwent pull-through intestine and intestinal anastomosis, and 39 patients underwent complete robotic intestine surgery and intestinal anastomosis. The hospitalization time of roboticassisted choledochocystectomy was 8.8 d. Eight patientshad biliary fistula and were all cured by conservative treatment and continuous observation. One patient had anastomotic stenosis, and one patient had wound dehiscence, both cured by surgery. Choledochocystectomy for children performed by completely robotic surgery and Roux-en-Y hepaticojejunostomy is safe and feasible. The initial experience shows that this surgical approach has a clearer field than the traditional endoscopy, and its operation is more flexible, the surgery is more accurate, and the injury is smaller. With the advancement of technology and the accumulation of surgeons' experience, robotic surgery may become a new trend in this surgical procedure.

Safety validation of decision trees for hepatocellular carcinoma

AIM: To evaluate a different decision tree for safe liver resection and verify its efficiency.METHODS: A total of 2457 patients underwent hepatic resection between January 2004 and December 2010 at the Chinese PLA General Hospital,and 634 hepatocellular carcinoma(HCC) patients were eligible for the final analyses. Post-hepatectomy liver failure(PHLF) was identified by the association of prothrombin time < 50% and serum bilirubin > 50 μmol/L(the "50-50" criteria),which were assessed at day 5 postoperatively or later. The Swiss-Clavien decision tree,Tokyo University-Makuuchi decision tree,and Chinese consensus decision tree were adopted to divide patients into two groups based on those decision trees in sequence,and the PHLF rates were recorded.RESULTS: The overall mortality and PHLF rate were 0.16% and 3.0%. A total of 19 patients experienced PHLF. The numbers of patients to whom the SwissClavien,Tokyo University-Makuuchi,and Chinese consensus decision trees were applied were 581,573,and 622,and the PHLF rates were 2.75%,2.62%,and 2.73%,respectively. Significantly more cases satisfied the Chinese consensus decision tree than the Swiss-Clavien decision tree and Tokyo University-Makuuchi decision tree(P < 0.01,P < 0.01); nevertheless,the latter two shared no difference(P = 0.147). The PHLF rate exhibited no significant difference with respect to the three decision trees.CONCLUSION: The Chinese consensus decision tree expands the indications for hepatic resection for HCC patients and does not increase the PHLF rate compared to the Swiss-Clavien and Tokyo UniversityMakuuchi decision trees. It would be a safe and effective algorithm for hepatectomy in patients with hepatocellular carcinoma.

Observation of the effects of three methods for reducing perineal swelling in children with developmental hip dislocation

BACKGROUND Developmental dysplasia of the hip is a developmental abnormality of the hip joint that results from hypoplasia during birth and continues to deteriorate after birth.AIM To observe the effects of magnesium sulfate wet compress,iodophor wet compress,and ice compress on reducing postoperative perineal swelling in children with developmental hip dislocation to provide effective nursing interventions in the clinic.METHODS A total of 120 children with hip dislocation after surgery in a third-class A hospital from January 2018 to January 2020 were randomly divided into four groups,the magnesium sulfate wet compress group,iodophor wet compress group,ice compress group and the control group.Data such as height,weight,age,duration of surgery,intraoperative blood loss,postoperative body temperature,swelling duration,pain score,and incidence of blisters were collected and analyzed.RESULTS There were no significant differences in height,weight,age,duration of surgery,intraoperative blood loss,and postoperative body temperature among the four groups of children.Statistical differences were observed between the intervention groups and the control group(P<0.05).CONCLUSION All three methods significantly reduced postoperative perineal swelling in children with developmental hip dislocation,reduced the duration of postoperative perineal swelling,reduced pain,and improved the quality of care.

Integrin αvβ6 sustains and promotes tumor invasive growth in colon cancer progression

AIM: To detect the mechanism by which colon tumor escapes the growth constraints imposed on normal cells by cell crowding and dense pericellular matrices.METHODS: An immunohistochemical study of integrin αvβ6 and matrix metalloproteinase-9(MMP-9) was performed on tissue microarrays of 200 spots, including 100 cases of colon tumors. RESULTS: High immunoreactivity for αvβ6(73.7%; 28/38) and MMP-9(76.5%; 52/68) was observed in invasive tumor portions. Furthermore, the effects of integrin αvβ6 on tumor invasive growth in nude mice were detected. Tumor invasive growth and high expression of both αvβ6 and MMP-9 were only seen in tumors resulting from Wi Dr cells expressing αvβ6 in the tumorigenicity assay. Flow cytometry was applied to analyze αvβ6 expression in colon cancer Wi Dr and SW480 cells. The effects of cell density on αvβ6 expression and MMP-9 secretion were also detected by Biotrak MMP-9 activity assay and gelatin zymography assay. High cell density evidently enhanced αvβ6 expression and promoted MMP-9 secretion compared with low density. CONCLUSION: Integrin αvβ6 sustains and promotes tumor invasive growth in tumor progression via a selfperpetuating mechanism. Integrin ανβ6-mediated MMP-9 secretion facilitates pericellular matrix degradation at high cell density, which provides the basis of invasive growth.

Retroperitoneoscopic approach for partial nephrectomy in children with duplex kidney: A case report

BACKGROUND Renal duplication is a common deformity of the urinary system,with an incidence of approximately 1/125 in children.Symptomatic patients with hydronephrosis,vesicoureteral reflux,or incontinence may require surgical interventions.Laparoscopy and retroperitoneoscopy are the two main accesses for partial nephrectomy.CASE SUMMARY A 9-year-old child was admitted to the hospital for hydronephrosis of the left kidney.Ultrasonography showed that the left kidney was larger,approximately 12.6 cm×6.3 cm×5.5 cm in size,with visible separation of the pelvis and an obviously separated lower portion.The upper segment of the left ureter was dilated(approximately 2.6 cm in width),and no significant dilation was observed in the middle and upper segments.The right kidney and ureter were normal.Primary diagnosis was left renal duplication malformation and hydronephrosis.Retroperitoneal laparoscopic nephrectomy and ureterectomy were performed.Intraoperative exploration revealed a dilated pelvis and thin renal parenchyma at the lower pole of the left kidney.The upper left kidney was smaller than normal,and the pelvis and ureter were larger than normal.The renal artery was blocked for 40 min.A hemolock was used to clamp down the kidney ureter,and a drainage tube was retained in the retroperitoneal cavity.The operation was uneventful,and the estimated amount of blood loss was 100 mL.Total abdominal drainage amount was 116 mL.The drainage tube was removed on postoperative day(POD)3 and the patient was discharged on POD6.The pathological diagnosis confirmed the atrophy of the renal parenchyma,the dilation of the renal pelvis,hydronephrosis,and ureteral cystic dilation.CONCLUSION The retroperitoneoscopic approach for partial nephrectomy is feasible and effective in selective pediatric patients with a duplex kidney.

Effects of positive acceleration(+Gz stress) on liver enzymes,energy metabolism,and liver histology in rats

BACKGROUND Exposure to high sustained +Gz(head-to-foot inertial load) is known to have harmful effects on pilots' body in flight. Although clinical data have shown that liver dysfunction occurs in pilots, the precise cause has not been well defined.AIM To investigate rat liver function changes in response to repeated +Gz exposure.METHODS Ninety male Wistar rats were randomly divided into a blank control group(BC group, n = 30), a +6 Gz/5 min stress group(6 GS group, n = 30), and a +10 Gz/5 min stress group(10 GS group, n = 30). The 6 GS and 10 GS groups were exposed to +6 Gz and +10 Gz, respectively, in an animal centrifuge. The onset rate of +Gz was 0.5 G/s. The sustained time at peak +Gz was 5 min for each exposure(for 5 exposures, and 5-min intervals between exposures for a total exposure and non-exposure time of 50 min). We assessed liver injury bymeasuring the portal venous flow volume, serum alanine aminotransferase(ALT)and aspartate aminotransferase(AST), liver tissue malondialdehyde(MDA), Na+-K+-ATPase, and changes in liver histology. These parameters were recorded at 0 h, 6 h, and 24 h after repeated +Gz exposures.RESULTS After repeated +Gz exposures in the 6 GS and the 10 GS groups, the velocity and flow signal in the portal vein(PV) were significantly decreased as compared to the BC group at 0 h after exposure. Meanwhile, we found that the PV diameter did not change significantly. However, rats in the 6 GS group had a much higher portal venous flow volume than the 10 GS group at 0 h after exposure. The 6 GS group had significantly lower ALT, AST, and MDA values than the 10 GS group 0 h and 6 h post exposure. The Na^+-K^+-ATPase activity in the 6 GS group was significantly higher than that in the 10 GS group 0 h and 6 h post exposure.Hepatocyte injury, determined pathologically, was significantly lower in the 6 GS group than in the 10 GS group.CONCLUSION Repeated +Gz exposures transiently cause hepatocyte injury and affect liver metabolism and morphological structure.

Robotic-assisted resection of ovarian tumors in children: A case report and review of literature

BACKGROUND Ovarian tumors are common gynecological diseases in children, and the most commonly seen ovarian tumors are germ cell tumors. Robotic surgery is the new access for children ovarian tumors.CASE SUMMARY From June to October 2017, 4 children with ovarian tumors were admitted and treated in the Department of Pediatric Surgery of People’s Liberation Army General Hospital. The mean age, height, and weight of these patients were 7.5(1-13) years old, 123.75(71-164) cm, and 36.8(8.5-69.5) kg, respectively. Roboticassisted resection of ovarian tumors was performed for all 4 patients. The 3-port approach was used for robotic manipulation. The surgical procedures were as follows. After creation of the pneumoperitoneum, the robotic scope was placed to explore and find the left ovarian tumor. The trocars for robotic arms 1 and 2 were placed at the sites to the lower right and left of the port of the scope. The tumor capsule in the fallopian tube was incised, and the tumor was completely stripped by an electric hook along the junction of the tumor and the capsule. The resected tumor was completely removed using an endobag. The average docking time of the robotic system was 18.5 min, the average operative time was 120 min, and the average blood loss was 20 m L. No drainage tube was placed except in one patient with a mucinous tumor of the ovary. No fever, pelvic fluid, or intestinal obstruction was reported after surgery. No antibiotics were used during the perioperative period, and the average length of hospital stay after surgery was 3 d.CONCLUSION Robotic-assisted resection of ovarian tumors is a simple, safe, and effective surgical procedure for selected patients.

Removal of pediatric stage Ⅳ neuroblastoma by robot-assisted laparoscopy: A case report and literature review

BACKGROUND Neuroblastoma (NB) is the most common extracranial solid tumor in children, with an incidence of approximately 1/10000. Surgical resection is an effective treatment for children with NB. Robot-assisted laparoscopic surgery is a new method and is superior to conventional laparoscopic surgery, since it has been preliminarily applied in clinical practice with a significant curative effect. This paper discusses significance and feasibility of complete resection of stage IV NB using robot-assisted laparoscopic surgery, while comparing its safety and effectiveness with conventional laparoscopic surgery. CASE SUMMARY In June 2018, a girl with stage IV retroperitoneal NB, aged 3 years and 5 mo, was admitted. Her weight was 15 kg, and her height was 100 cm. Robot-assisted, fiveport laparoscopic resection of NB was performed. Starting from the middle point between the navel and the anterior superior iliac spine to the left lower abdomen, the pneumoperitoneum and observation hole (10 mm) were established using the Hasson technique. Operation arm #1 was located between the left anterior axillary line, the navel, and the costal margin (8 mm);operation arm #2 was located at the intersection of the right anterior axillary line and Pfannenstiel line (8 mm);one auxiliary hole was located between arm #2 (on the Pfannenstiel line) and the observation hole (12 mm);and another auxiliary hole (5 mm) was located slightly below the left side of the xiphoid. Along the right line of Toldt and the hepatic flexure of the transverse colon, the colon was turned to the left and below with a hook electrode. Through Kocher's incision, the duodenum and the pancreatic head were turned to the left to expose the inferior vena cava and the abdominal aorta. The vein was separated along the right external iliac, and the inferior vena cava was then lifted to expose the right renal vein from the bottom to the top. The tumor was transected horizontally below the renal vein, and it was first cut into pieces and then resected. The right renal artery and the left renal vein were also exposed, and the retrohepatic inferior vena cava was isolated. The tumor was resected along the surface of the psoas muscle, the back of the inferior vena cava, and the right side of the abdominal aorta. Finally, the lymph node metas-tases in front of the abdominal aorta and left renal vein were completely removed. The specimens were loaded into a disposable specimen retrieval bag and removed from the enlarged auxiliary hole. T-tube drainage was placed and brought out through a hole in the right lower quadrant of the abdomen. The operative time was 389 min, the time of pneumoperitoneum was 360 min, the intraoperative blood loss was approximately 200 mL, and the postoperative recovery was smooth. There were no complications, such as lymphatic fistula, diarrhea, bleeding, and paralytic ileus. Two months after discharge, there were no other complications. The literature on the application of robot-assisted laparoscopic surgery in the treatment of NB in children was reviewed CONCLUSION The robot has the advantages of a three-dimensional view and flexible operation, and it can operate finely along blood vessels. The successful experience of this case confirmed that robot-assisted laparoscopic surgery can skeletonize the abdominal blood vessels in the tumor and cut the tumor into pieces, indicating that robot-assisted laparoscopic surgery is feasible.

Portal inflow preservation during portal diversion in small-for-size syndrome

AIM: To investigate the impact of portal inflow on liver remnants in a stable pig model of small-for-size syndrome.

Laparoscopic pancreaticoduodenectomy via a reverse-''V'' approach with four ports:Initial experience and perioperative outcomes

AIM:To evaluate the feasibility,safety,and efficacy of laparoscopic pancreaticoduodenectomy(LPD) using a reverse-"V" approach with four ports.METHODS:This is a retrospective study of selected patients who underwent LPD at our center between April 2011 and April 2012.The following data were collected and reviewed:patient characteristics,tumor histology,surgical outcome,resection margins,morbidity,and mortality.All patients were thoroughly evaluated preoperatively by complete hematologic investigations,triple-phase helical computed tomography,upper gastrointestinal endoscopy,and biopsy of ampullary lesions(when present).Magnetic resonance cholangiopancreatography was performed for doubtful cases of lower common bile duct lesions.RESULTS:There was no perioperative mortality.LPD was performed with tumor-free margins in all patients,including patients with pancreatic ductal adenocarcinoma(n = 6),ampullary carcinoma(n = 6),intra-ductal papillary mucinous neoplasm(n = 2),pancreatic cystadenocarcinoma(n = 2),pancreatic head adenocarcinoma(n = 3),and bile duct cancer(n = 2).The mean patient age was 65 years(range,42-75 years).The median blood loss was 240 m L,and the mean operative time was 368 min.CONCLUSION:LPD using a reverse-"V" approach can be performed safely and yields good results in elective patients.Our preliminary experience showed that LDP can be performed via a reverse-"V" approach.This approach can be used to treat localized malignant lesions irrespective of histopathology.