Preoperative systemic inflammatory response index as a prognostic marker for distal cholangiocarcinoma after pancreatoduodenectomy

BACKGROUND The relationship between preoperative inflammation status and tumorigenesis as well as tumor progression is widely acknowledged.AIM To assess the prognostic significance of preoperative inflammatory biomarkers in patients with distal cholangiocarcinoma(dCCA)who underwent pancreat-oduodenectomy(PD).METHODS This single-center study included 216 patients with dCCA after PD between January 1,2011,and December 31,2022.The individuals were categorized into two sets based on their systemic inflammatory response index(SIRI)levels:A low SIRI group(SIRI<1.5,n=123)and a high SIRI group(SIRI≥1.5,n=93).Inflam-matory biomarkers were evaluated for predictive accuracy using receiver operating characteristic curves.Both univariate and multivariate Cox proportional hazards analyses were performed to estimate SIRI for overall survival(OS)and recurrence-free survival(RFS).RESULTS The study included a total of 216 patients,with 58.3%being male and a mean age of 65.6±9.6 years.123 patients were in the low SIRI group and 93 were in the high SIRI group after PD for dCCA.SIRI had an area under the curve value of 0.674 for diagnosing dCCA,showing better performance than other inflammatory biomarkers.Multivariate analysis indicated that having a SIRI greater than 1.5 independently increased the risk of dCCA following PD,leading to lower OS[hazard ratios(HR)=1.868,P=0.006]and RFS(HR=0.949,P<0.001).Additionally,survival analysis indicated a significantly better prognosis for patients in the low SIRI group(P<0.001).CONCLUSION It is determined that a high SIRI before surgery is a significant risk factor for dCCA after PD.

Does antecolic reconstruction decrease delayed gastric emptying after pancreatoduodenectomy?

Delayed gastric emptying(DGE) is a frequent complication after pylorus-preserving pancreatoduodenectomy(PpPD).Kawai and colleagues proposed pylorus-resecting pancreatoduodenectomy(PrPD) with antecolic gastrojejunal anastomosis to obviate DGE occurring after PpPD.Here we debate the reported differences in the prevalence of DGE in antecolic and retrocolic gastro/duodeno-jejunostomies after PrPD and PpPD,respectively.We concluded that the route of the gastro/duodeno-jejunal anastomosis with respect to the transverse colon;i.e.,antecolic route or retrocolic route,is not responsible for the differences in prevalence of DGE after pancreatoduodenectomy(PD) and that the impact of the reconstructive method on DGE is related mostly to the angulation or torsion of the gastro/duodeno-jejunostomy.We report a prevalence of 8.9% grade A DGE and 1.1% grade C DGE in a series of 89 subtotal stomach-preserving PDs with Roux-en Y retrocolic reconstruction with anastomosis of the isolated Roux limb to the stomach and single Roux limb to both the pancreatic stump and hepatic duct.Retrocolic anastomosis of the isolated first jejunal loop to the gastric remnant allows outflow of the gastric contents by gravity through a "straight route".

Hepatopancreatoduodenectomy for advanced hepatobiliary malignancies: a single-center experience

BACKGROUND: Hepatopancreatoduodenectomy is a complicated and challenging procedure but necessary for curative resection for advanced hepatobiliary malignancies. This retrospective study was to examine the safety and survival outcomes of hepatopancreatoduodenectomy in our center. METHODS: Prospectively collected data of 12 patients who underwent hepatopancreatoduodenectomy for advanced hepatobiliary malignancies in our hospital from January 1998 to December 2014 were analyzed. The primary endpoints are treatment-related morbidity and mortality and the secondary endpoints are overall survival and disease-free survival. RESULTS: Curative resection was achieved in 11 (91.7%) patients. Complications developed in 10 (83.3%) patients. Three hospital deaths resulted from multiorgan failure secondary to postoperative pancreatic fistula or hepaticojejunostomy leakage. Six of the nine remaining patients had disease recurrence. The nine patients had a median survival of 39.8 (5.3-151.8) months. The 1-, 3- and 5-year overall survival rates were 66.7%, 55.6% and 27.8%, respectively. The corresponding disease-free survival rates were 55.6%, 44.4% and 29.6%, respectively. CONCLUSIONS: Morbidity and mortality after hepatopancreatoduodenectomy were significant. With RO resection, the 5-year overall survival and disease-free survival rates were 27.8% and 29.6%, respectively.

Pancreatoduodenectomy with Simultaneous Venous Resection for Advanced Ductal Pancreatic Head Cancer:A Case Control Study

Introduction: Surgical resection is the treatment of choice for pancreatic ductal adenocarcinoma (PDA). However, in case of venous tumor in-volvement, carcinomas are classified as borderline resectable and their preferential therapy remains controversial. The purpose of this study is to analyze the effectiveness of the surgical approach with simultaneous venous resection regarding perioperative outcome and long-term survival. Patients and methods: All patients that underwent pancreatoduodenectomy (PD) for PDA at our institution between 02/2002 and 12/2016 were analyzed retrospectively. A matched-pair analysis between patients that underwent PD with simultaneous venous resection (PDVR) and standard PD was performed to compare perioperative parameters, survival and factors relevant to long-term survival. Results: The study included 142 patients: 71 underwent PDVR and 71 underwent standard PD. Venous tumor infiltration could histopathologically be confirmed in 21 patients (29.58%). PDVR wasn’t associated with a higher rate of postoperative complications (56.34% for both groups), severe postoperative complications (28.17% vs. 23.94%) and mortality (5.63% vs. 9.86%) compared to standard PD. Median overall survival of both groups was 17 months (95% CI 10.89 - 23.11), without statistical significance between the two groups (PD 22 months, 95% CI 16.02 - 27.99 vs. PDVR 16 months, 95% CI 9.96 - 22.04, p = 0.087). Parameters associated with overall survival were his-topathologically proven venous tumor infiltration, the lymph node status and the necessity of postoperative blood transfusions. Conclusion: PDVR is justified, because peri- and post-operative morbidity and mortality, as well as long-term survival, are comparable to standard PD. Even in case of postoperatively histopathologically confirmed venous tumor infiltration, patients benefit over palliative treatment.

The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy

BACKGROUND:A number of definitions have been used for delayed gastric emptying(DGE) after pancreatoduodenectomy and the reported rates varied widely.The International Study Group of Pancreatic Surgery(ISGPS) definition is the current standard but it is not used universally.In this comprehensive review,we aimed to determine the acceptance rate of ISGPS definition of DGE,the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence.DATA SOURCE:We searched PubM ed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition,DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles.RESULTS:Out of 435 search results,178 were selected for data extraction.The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7%(range:0-100%;median:18.7%) and 14.3%(range:1.8%-58.2%;median:13.6%),respectively.Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates.Although pyloric dilatation,Braun’s entero-enterostomy and Billroth Ⅱ reconstruction were associated with significantly lower DGE rates,pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies.CONCLUSIONS:ISGPS definition of DGE has been used in majority of studies published after 2010.Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications.Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.

Risk prediction platform for pancreatic fistula after pancreatoduodenectomy using artificial intelligence

BACKGROUND Despite advancements in operative technique and improvements in postoperative managements,postoperative pancreatic fistula(POPF)is a life-threatening complication following pancreatoduodenectomy(PD).There are some reports to predict POPF preoperatively or intraoperatively,but the accuracy of those is questionable.Artificial intelligence(AI)technology is being actively used in the medical field,but few studies have reported applying it to outcomes after PD.AIM To develop a risk prediction platform for POPF using an AI model.METHODS Medical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016.A total of 38 variables were inserted into AI-driven algorithms.The algorithms tested to make the risk prediction platform were random forest(RF)and a neural network(NN)with or without recursive feature elimination(RFE).The median imputation method was used for missing values.The area under the curve(AUC)was calculated to examine the discriminative power of algorithm for POPF prediction.RESULTS The number of POPFs was 221(12.5%)according to the International Study Group of Pancreatic Fistula definition 2016.After median imputation,AUCs using 38 variables were 0.68±0.02 with RF and 0.71±0.02 with NN.The maximal AUC using NN with RFE was 0.74.Sixteen risk factors for POPF were identified by AI algorithm:Pancreatic duct diameter,body mass index,preoperative serum albumin,lipase level,amount of intraoperative fluid infusion,age,platelet count,extrapancreatic location of tumor,combined venous resection,co-existing pancreatitis,neoadjuvant radiotherapy,American Society of Anesthesiologists’score,sex,soft texture of the pancreas,underlying heart disease,and preoperative endoscopic biliary decompression.We developed a web-based POPF prediction platform,and this application is freely available at http://popfrisk.smchbp.org.CONCLUSION This study is the first to predict POPF with multiple risk factors using AI.This platform is reliable(AUC 0.74),so it could be used to select patients who need especially intense therapy and to preoperatively establish an effective treatment strategy.

Treatment of massive pancreaticojejunal anastomotic hemorrhage after pancreatoduodenectomy

AIM： To compare the treatment modalities for patients with massive pancreaticojejunal anastomotic hemorrhage after pancreatoduodenectomy （PDT）.METHODS： A retrospective study was undertaken to compare the outcomes of two major treatment modalities： transcatheter arterial embolization （TAE） and open surgical hemostasis. Seventeen patients with acute massive hemorrhage after PDT were recruited in this study. A comparison of two treatment modalities was based upon the clinicopathological characteristics and hospitalization stay, complications, and patient prognosis of the patients after surgery.RESULTS： Of the 11 patients with massive hemorrhage after PDT treated with TAE, 1 died after discontinuing treatment, the other 10 stopped bleeding completely without recurrence of hemorrhage. AIJ the 10 patients recovered well and were discharged, with a mean hospital stay of 10.45 d after hemostasis. The patients who underwent TAE twice had a re-operation rate of 18.2% and a mortality rate of 0.9%. Among the six patients who received open surgical hemostasis, two underwent another round of open surgical hemostasis. The mortality was 50%, and the recurrence of hemorrhage was 16.67%, with a mean hospital stay of 39.5 d.CONCLUSION： TAE is a safe and effective treatment modality for patients with acute hemorrhage after PDT. Vasography should be performed to locate the bleeding site.

Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy

BACKGROUND Pancreatic fistula is one of the most serious complications after pancreatoduodenectomy for treating any lesions at the pancreatic head. For years, surgeons have tried various methods to reduce its incidence. AIM To investigate and emphasize the clinical outcomes of Blumgart anastomosis compared with traditional anastomosis in reducing postoperative pancreatic fistula. METHODS In this observational study, a retrospective analysis of 291 patients who underwent pancreatoduodenectomy, including Blumgart anastomosis (201 patients) and traditional embedded pancreaticojejunostomy (90 patients), was performed in our hospital. The preoperative and perioperative courses and longterm follow-up status were analyzed to compare the advantages and disadvantages of the two methods. Moreover, 291 patients were then separated by the severity of postoperative pancreatic fistula, and two methods of pancreaticojejunostomy were compared to detect the features of different anastomosis. Six experienced surgeons were involved and all of them were proficient in both surgical techniques.RESULTS The characteristics of the patients in the two groups showed no significant differences, nor the preoperative information and pathological diagnoses. The operative time was significantly shorter in the Blumgart group (343.5 ± 23.0 vs 450.0 ± 40.1 min, P = 0.028), as well as the duration of pancreaticojejunostomy drainage tube placement and postoperative hospital stay (12.7 ± 0.9 d vs 17.4 ± 1.8 d, P = 0.031;and 21.9 ± 1.3 d vs 28.9 ± 1.3 d, P = 0.020, respectively). The overall complications after surgery were much less in the Blumgart group than in the embedded group (11.9% vs 26.7%, P = 0.002). Patients who underwent Blumgart anastomosis would suffer less from severe pancreatic fistula (71.9% vs 50.0%, P = 0.006), and this pancreaticojejunostomy procedure did not have worse influences on long-term complications and life quality. Thus, Blumgart anastomosis is a feasible pancreaticojejunostomy procedure in pancreatoduodenectomy surgery. It is safe in causing less postoperative complications, especially pancreatic fistula, and thus shortens the hospitalization duration. CONCLUSION Surgical method should be a key factor in reducing pancreatic fistula, and Blumgart anastomosis needs further promotion.

Comparison of Wirsung-jejunal duct-tomucosa and dunking technique for pancreatojejunostomy after pancreatoduodenectomy

Pancreato-enteric reconstruction after pancreatoduodenectomy (PD) is still a source of debate because of the high incidence of complications. Among the various types of pancreato-jejunostomies we don't know yet which is the best in terms of anastomotic failure and related complications rates. Wirsung-jejunal duct-to-mucosa anastomosis (WJ) and 'dunking' pancreato-jejunal anastomosis (DPJ) are the two most used ones worldwide but conflicting results are reported. To determine which is the safer anastomosis and to define when an anastomosis should be preferred, we retrospectively reviewed two groups of patients who underwent WJ or DPJ. METHODS:Twenty-three patients underwent PD with WJ (n=17) with dilated (WJD) (n=9) or not-dilated Wirsung's duct (WJND) (n=8) or with a DPJ (n=6) over a 3-year period at a single institution. RESULTS: The complications rate was high in all groups of patients (33.3% in WJD, 37.5% in WJND and 66.7% in DPJ). A pancreatic fistula developed in one patient in each group (11. 1% in WJD, 12. 5% in WJND and 16. 7% in DPJ). All these patients were managed conservatively. Anastomotic disruption took place in the WJ patients especially in the WJND group (n=2) compared to the WJD (n=1) (25% vs 11.1%) or DPJ groups (0%) : these three patients required a re-operation. Overall, the anastomotic defects were higher in patients who underwent WJND (37.5%), compared to WJD (22.2%) and to DPJ (16.7%). However, no statistical differences were found among the groups. Delayed gastric emptying (DGE) and total parenteral nutrition (TPN) along with anastomotic defects were responsible for a prolonged hospital stay. CONCLUSIONS:Our results were not able to demonstrate any statistical difference between the two different techniques in preventing anastomotic failure. WJ can represent a valid choice in case of a dilated duct and a firm, fibrotic enlarged gland that could not be properly invaginated in a small jejunal loop. DGE may occur in those patients who experienced an anastomotic failure and required a TPN regimen with a prolonged hospital stay.

Impaired immune reaction and increased lactate and C-reactive protein for early prediction of severe morbidity and pancreatic fistula after pancreatoduodenectomy

Background: Prediction of complications after pancreatoduodenectomy (PD) remains of interest. Blood parameters and biomarkers during rst and second postoperative days (POD1, POD2) may be early indi- cators of complications. Methods: This case-control study included 50 patients. Baseline, POD1 and POD2 values of leukocytes, neutrophils, lymphocytes, platelets, hemoglobin, C-reactive protein (CRP), procalcitonin and arterial lactate were compared between individuals presenting Clavien ≥ III morbidity, pancreatic stula (PF) or clinically relevant PF (CRPF) and those without these morbidities. Common variables reaching signi cance were further analyzed in order to calculate a predictive score. Results: Severe morbidity, PF and CRPF rates were 28.0%, 26.0% and 14.0%, respectively. Patients with severe morbidity had lower leukocytes on POD2 (P=0.04). Patients with PF presented higher CRP on POD2 (P=0.001), higher lactate on POD1 (P=0.007) and POD2 (P=0.008), and lower lymphocytes on POD1 (P=0.007) and POD2 (P=0.008). Patients with CRPF had lower leukocytes and neutrophils on POD1 (P =0.048, P =0.038), lower lymphocytes on POD1 (P =0.001) and POD2 (P =0.003), and higher CRP on POD2 (P =0.001). Baseline parameters and procalcitonin obtained no statistical associations. Score was de ned according to lymphocytes on POD1 < 650/μL and CRP on POD2 ≥ 250 mg/L allocating patients in 3 risk categories. PF and CRPF rates were statistically higher as risk category increased (P<0.001). Receiver operating characteristic curves and Hosmer Lemeshow tests showed a good accuracy. Conclusions: Impaired immunological reaction during early postoperative period (lower leukocytes and, particularly, lymphocytes) in response to surgical aggression would favor complications after PD. Likewise, acidosis (higher arterial lactate) could behave as risk factor of PF. An elevated CRP on POD2 is also an early biomarker of PF. Our novel score based on postoperative lymphocyte count and CRP seems reliable for early prediction of PF.

Modified Blumgart anastomosis without pancreatic duct-to-jejunum mucosa anastomosis for pancreatoduodenectomy：a feasible and safe novel technique

Objective：This study proposed a modified Blumgart anastomosis（m-BA）that uses a firm ligation of the main pancreatic duct with a supporting tube to replace the pancreatic duct-to-jejunum mucosa anastomosis,with the aim of simplifying the complicated steps of the conventional BA（c-BA）.Thus,we observe if a difference in the risk of postoperative pancreatic fistula（POPF）exists between the two methods.Methods：The m-BA anastomosis method has been used since 2010.From October 2011 to October 2015,147 patients who underwent pancreatoduodenectomy（PD）using BA in Tianjin Medical University Cancer Institute and Hospital were enrolled in this study.According to the type of pancreatojejunostomy（PJ）,50 patients underwent m-BA and 97 received c-BA.The two patient cohorts were compared prospectively to some extent but not randomized,and the evaluated variables were operation time,the incidence rate of POPF,and other perioperative complications.Results：The operation time showed no significant difference（P〉0.05）between the two groups,but the time of duct-to-mucosa anastomosis in the m-BA group was much shorter than that in the c-BA group（P〈0.001）.The incidence rate of clinically relevant POPF was 12.0%（6/50）in the modified group and 10.3%（10/97）in the conventional group（P〉0.05）,which means that the modified anastomosis method did not cause additional pancreatic leakage.The mean length of postoperative hospital stay of the m-BA group was 23 days,and that of the c-BA group was 22 days（P〉0.05）.Conclusions：Compared with the conventional BA,we suggest that the modified BA is a feasible,safe,and effective operation method for P J of PD with no sacrifice of surgical quality.In the multivariate analysis,we also found that body mass index（≥25

CD14 upregulation as a distinct feature of non-alcoholic fatty liver disease after pancreatoduodenectomy

AIM:To investigate the pathogenesis of non-alcoholic fatty liver disease(NAFLD)after pancreatoduodenectomy(PD).METHODS:A cohort of 82 patients who underwent PD at Okayama University Hospital between 2003 and 2009 was enrolled and the clinicopathological features were compared between patients with and without NAFLD after PD.Computed tomography(CT)images were evaluated every 6 mo after PD for follow-up.Hepatic steatosis was diagnosed on CT when hepatic attenuation values were 40 Hounsfield units.Liver biopsy was performed for 4 of 30 patients with NAFLD after PD who consented to undergo biopsies.To compare NAFLD after PD with NAFLD associated with metabolic syndrome,liver samples were obtained from 10 patients with NAFLD associated with metabolic syndrome [fatty liver,n = 5;non-alcoholic steatohepatitis(NASH),n = 5] by percutaneous ultrasonography-guided liver biopsy.Double-fluorescence immunohistochemistry was applied to examine CD14 expression as a marker of lipopolysaccharide(LPS)-sensitized macrophage cells(Kupffer cells)in liver biopsy specimens.RESULTS:The incidence of postoperative NAFLD was 36.6%(30/82).Univariate analysis identified cancer of the pancreatic head,sex,diameter of the main pancreatic duct,and dissection of the nerve plexus as factors associated with the development of NAFLD after PD.Those patients who developed NAFLD after PD demonstrated significantly decreased levels of serum albumin,total protein,cholesterol and triglycerides compared to patients without NAFLD after PD,but no glucose intolerance or insulin resistance.Liver biopsy was performed in four patients with NAFLD after PD.All four patients showed moderate-to-severe steatosis and NASH was diagnosed in two.Numbers of cells positive for CD68(a marker of Kupffer cells)and CD14(a marker of LPSsensitized Kupffer cells)were counted in all biopsy specimens.The number of CD68+ cells in specimens of NAFLD after PD was significantly increased from that in specimens of NAFLD associated with metabolic syndrome specimens,which indicated the presence of significantly more Kupffer cells in NAFLD after PD than in NAFLD associated with metabolic syndrome.Similarly,more CD14+ cells,namely,LPS-sensitized Kupffer cells,were observed in NAFLD after PD than in NAFLD associated with metabolic syndrome.Regarding NASH,more CD68+ cells and CD14+ cells were observed in NASH after PD specimens than in NASH associated with metabolic syndrome.This showed that more Kupffer cells and more LPS-sensitized Kupffer cells were present in NASH after PD than in NASH associated with metabolic syndrome.These observations suggest that after PD,Kupffer cells and LPS-sensitized Kupffer cells were significantly upregulated,not only in NASH,but also in simple fatty liver.CONCLUSION:NAFLD after PD is characterized by both malnutrition and the up-regulation of CD14 on Kupffer cells.Gut-derived endotoxin appears central to the development of NAFLD after PD.

Reconstruction after pancreatoduodenectomy:Pancreatojejunostomy vs pancreatogastrostomy

Pancreatic surgeons try to find the best technique for reconstruction after pancreatoduodenectomy(PD) in order to decrease postoperative complications,mainly pancreatic fistulas(PF).In this work,we compare the two most frequent techniques of reconstruction after PD,pancreatojejunostomy(PJ) and pancreatogastrostomy(PG),in order to determine which of the two is better.A systematic review of the literature was performed,including major meta-analysis articles,clinical randomized trials,systematic reviews,and retrospective studies.A total of 64 articles were finally included.PJ and PG are usually responsible for most of the postoperative morbidity,mainly due to the onset of PF,being considered a major trigger of life-threatening complications such as intra-abdominal abscess and hemorrhagia.The included systematic reviews reported a significant difference only in the incidence of intraabdominal collections favouring PG.PF,delayed gastric emptying and mortality were not different.Although there was heterogeneity between these studies,all were conducted in specialized centers by highly experienced surgeons,and the surgical care was likely to be similar for all the studies.The disadvantages of PG include an increased incidence of delayed gastric emptying and of main pancreatic duct obstruction due to overgrowth by the gastric mucosa.Exocrine function appears to be worse after PG than after PJ,resulting in severe atrophic changes in the remnant pancreas.Depending on the type of PJ or PG used,the PF rate and other complications can also be different.The best method to deal with the pancreatic stump after PD remains questionable.The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon's preference and adherence to basic principles such as good exposure and visualization.In conclusion,up to now none of the techniques can be considered superior or be recommended as standard for reconstruction after PD.

Repair of the portal vein using a hepatic ligamentum teres patch for laparoscopic pancreatoduodenectomy: A case report

BACKGROUND Laparoscopic pancreatoduodenectomy (LPD) has been developed gradually with the advances in surgical laparoscopic techniques. It is technically challenging to perform LPD with portal vein resection and reconstruction. CASE SUMMARY A 71-year-old female patient was diagnosed with distal cholangiocarcinoma. After preoperative examination and rigorous preoperative preparation, the patient underwent LPD using 3D laparoscopy on July 17, 2018. During the surgery, we found that the tumor invaded the right wall of the portal vein;thus, pancreaticoduodenectomy combined with partial portal vein wall resection was performed. The defect of the portal vein wall was approximately 2.5 cm × 1.0 cm. The hepatic ligamentum teres was excised by laparoscopy and then recanalized in vitro. Following recanalization, the hepatic ligamentum teres was cut longitudinally and then trimmed into vascular patches that were then used to reconstruct the defect of the portal vein through 3D laparoscopy. The operative time was 560 min, and intraoperative blood loss was 100 mL. The duration of the blood occlusion time was 63 min. No blood transfusion was required. The patient underwent enhanced recovery after surgery procedures after the operation. The patient was discharged on postoperative day 11. Follow-up for 6 months after discharge showed no stenosis of the portal vein and good patency of blood flow. CONCLUSION It is safe and feasible to use the hepatic ligamentum teres patch to repair portal vein in LPD. However, the long-term patency of this technique for venous reconstruction requires further investigation.

Arterial embolization is the best treatment for pancreaticojejunal anastomotic bleeding after pancreatoduodenectomy

Massive pancreaticojejunal anastomotic bleeding, mainly from the gastroduodenal stump, is one of the most common complications of pancreato-duodenectomy. Selective angiography should be systematically the first step of investigative procedure in such situations. Pharmacoarteriography may be used if the bleeding point is not spontaneously identified, and allows safe and effective treatment with transcatheter arterial embolization compared to blind open surgical hemostasis. Coil embolization of the common or proper hepatic artery on either side of the bleeding point with "sandwich technique" is then the preferred technique to prevent retrograde filling. Surgery should be performed only as a last resort.

Pancreas-preserving duodenal resections vs pancreatoduodenectomy for groove pancreatitis. Should we revisit treatment algorithm for groove pancreatitis?

BACKGROUND The management of cystic dystrophy of the duodenal wall(CDDW),or groove pancreatitis(GP),remains controversial.Although pancreatoduodenectomy(PD)is considered the most suitable operation for CDDW,pancreas-preserving duodenal resection(PPDR)has also been suggested as an alternative for the pure form of GP(isolated CDDW).There are no studies comparing PD and PPDR for this disease.AIM To compare the safety,efficacy,and short-and long-term results of PD and PPDR in patients with CDDW.METHODS A retrospective analysis of the clinical,radiologic,pathologic,and intra-and postoperative data of 84 patients with CDDW(2004-2020)and a comparison of the safety and efficacy of PD and PPDR.RESULTS Symptoms included abdominal pain(100%),weight loss(76%),vomiting(30%)and jaundice(18%)and data from computed tomography,magnetic resonance imaging,and endoUS led to the correct preoperative diagnosis in 98.8%of cases.Twelve patients were treated conservatively with pancreaticoenterostomy(n=8),duodenum-preserving pancreatic head resection(n=6),PD(n=44)and PPDR(n=15)without mortality.Weight gain was significantly higher after PD and PPDR and complete pain control was achieved significantly more often after PPDR(93%)and PD(84%)compared to the other treatment modalities(18%).New onset diabetes mellitus and severe exocrine insufficiency occurred after PD(31%and 14%),but not after PPDR.CONCLUSION PPDR has similar safety and better efficacy than PD in patients with CDDW and may be the optimal procedure for the isolated form of CDDW.The pure form of GP is a duodenal disease and PD may be an overtreatment for this disease.Early detection of CDDW provides an opportunity for pancreas-preserving surgery.

A Modified Surgical Approach of Hepatopancreatoduodenectomy for Advanced Gallbladder Cancer:Report of Two Cases and Literature Review

Gallbladder cancer（GBC） is the most common cancer of the biliary tract, constituting 80%–95% of malignant biliary tract tumors. Surgical resection is currently regarded as the sole curative treatment for GBC. Hepatopancreatoduodenectomy（HPD） has been adopted to remove the advanced gallbladder tumor together with the infiltrated parts within the liver, lower biliary tract and the peripancreatic region of GBC patients. However, patients who underwent HPD were reported to have a distinctly higher postoperative morbidity（71.4%, ranging from 30.8% to 100%） and mortality（13.2%, ranging from 2.4% to 46.9%） than those given pancreatoduodenectomy（PD） alone. We present two patients with advanced GBC who underwent a modified surgical approach of HPD： PD with microwave ablation（MWA） of adjacent liver tissues and the technique of intraductal cooling of major bile ducts. No serious complications like bile leakage, pancreatic fistula, hemorrhage and organ dysfunction, etc. occurred in the two patients. They had a rapid recovery with postoperative hospital stay being 14 days. Application of this approach effectively eliminated tumor-infiltrated adjacent tissues, and maximally reduced the postoperative morbidity and mortality. This modified surgical method is secure and efficacious for the treatment of locally advanced GBC.

Hepatopancreatoduodenectomy for the treatment of extrahepatic cholangiocarcinoma

To the Editor:Extrahepatic cholangiocarcinoma(ECC)is an uncommon neoplasm associated with a poor prognosis[1-3].Surgical resection represents the only curative approach,since systemic treatments have scarce efficacy in achieving disease control.However,only 10%-40%of patients with ECC are resectable at diagnosis[1].Ma-jor hepatectomy and portal lymphadenectomy are usually required for hilar ECC,while pancreatoduodenectomy is the standard operation for distal ECC[3-5].However,ECC may spread horizon-tally along the biliary tree,causing tumor involvement of the entire extrahepatic biliary system.In these circumstances,hep-atopancreatoduodenectomy(HPD)has been proposed as a pro-cedure with curative intent[2,6,7].

Laparoscopic pancreatoduodenectomy:How far have we come and where are we headed?

Minimally invasive pancreatoduodenectomy is currently a feasible option in selected patients at high volume centers with available expertise. Although the procedure hasbeen described two decades ago, laparoscopic surgeons have been reluctant to perform it since it is technically demanding. Currently there is no standardized training process for minimally invasive pancreatoduodenectomy and this is required to ensure the safety of the procedure. Even the open pancreatoduodenectomy can be a challenging procedure where the outcome depends much upon the patient volume and surgeon's experience. In the minimally invasive setting, all the current evidence comes from retrospective data with inherent selection bias. Although the proposed benefits have been reported in many series, a randomized trial comparing with the open approach is highly unlikely to happen, given the complexity of pancreatic cancer and patient selection for complex surgery. Rather, in a disease for which cure is an utopian statement, perhaps the ultimate aim of minimally invasive pancreatoduodenectomy can be the improvement in the quality of life. Also further studies are needed to assess the immunologic role affecting the oncologic outcomes in patients undergoing minimally invasive pancreatoduodenectomy. The robotic platforms have got easily accepted since they can overcome some of the limitations of the laparoscopic platforms such as limited range of motion, two dimensional visualization and poor ergonomics. The main limitations of robotic procedures are related to the high costs associated with the system and disposable equipment. Currently evidence is lacking regarding the cost effectiveness of the procedure and also the push from the industry is on rise. All these minimally invasive techniques have a long learning curve and prior extensive experience in hepatopancreatobiliary surgery is mandatory for surgeons embarking on these endeavours.