Endoscopic treatment of biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants: Lessons learned from single-balloon enteroscopy-assisted ERCP

Background: Endoscopic treatment of biliopancreatic pathology is challenging due to surgically altered anatomy after Whipple's pancreaticoduodenectomy. This study aimed to evaluate the feasibility and safety of single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography(SBE-ERCP) to treat biliopancreatic pathology in patients with Whipple's pancreaticoduodenectomy surgical variants. Methods: We retrospectively analyzed 106 SBE-ERCP procedures in 46 patients with Whipple's variants. Technical and clinical success rates and adverse events were evaluated. Results: Biliary SBE-ERCP was performed in 34 patients and pancreatic SBE-ERCP in 17, including 5 with both indications. From a total of 106 SBE-ERCP procedures, 76 were biliary indication with technical success rate of 68/76(90%) procedures and clinical success rate of 30/34(88%) patients. Mild adverse event rate was 8/76(11%), without serious adverse events. From a total of 106 SBE-ERCP procedures, 30 were pancreatic indication with technical success rate of 24/30(80%) procedures( P = 0.194 vs. biliary SBEERCP) and clinical success rate of 11/17(65%) patients( P = 0.016 vs. biliary SBE-ERCP). Mild adverse event rate was 6/30(20%)( P = 0.194 vs. biliary SBE-ERCP), without serious adverse events. After SBE-ERCP failure, endoscopic ultrasound-guided drainage, percutaneous drainage and redo surgery were alternative therapeutic options. Conclusions: Biliopancreatic pathology after Whipple's pancreaticoduodenectomy variants can be treated using SBE-ERCP without serious adverse events. Technical and clinical success rates are high for biliary indications, whereas clinical success rate of pancreatic indications is significantly lower. SBE-ERCP can be considered as first-line treatment option in this patient group with surgically altered anatomy.

Isolated Pancreatic Tuberculosis in Non-immunocompromised Patient Treated by Whipple's Procedure:a Case Report

PANCREATIC tuberculosis(TB)is a rare disease and its diagnosis is difficult because of the lack of specific clinical manifestations.Computed tomography(CT)and magnetic resonance imaging(MRI)have some diagnostic values in this disease,but it is easy to misdiagnose pancreatic TB as a pancreatic tumor.1 In this article,we present a case of non-immunocompromised patient developing an isolated pancreatic TB,report the CT and MRI findings,and the surgical procedure for it.

Role of original and modified Frey's procedures in chronic pancreatitis

AIM To retrospectively review patients with chronic pancreatitis(CP) treated with Frey's procedures between January 2009 and January 2014.METHODS A retrospective review was performed of patients with CP treated with Frey's procedures between January 2009 and January 2014 in the Department of Pancreatic Surgery. A cross-sectional study of postoperative pain relief, quality of life(Qo L), and alcohol and nicotine abuse was performed by clinical interview, letters and telephone interview in January 2016. Qo L of patients was evaluated with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire(EORTC QLQ-C30) version 3.0. The patients were requested to fill in the questionnaires by themselves via correspondence or clinical interview.RESULTS A total of 80 patients were enrolled for analysis, including 44 who underwent the original Frey's procedure and 36 who underwent a modified Frey's procedure. The mean age was 46 years in the original group and 48 years in the modified group. Thirtyfive male patients(80%) were in the original group and 33(92%) in the modified group. There were no differences in the operating time, blood loss, and postoperative morbidity and mortality between the two groups. The mean follow-up was 50.3 mo in the original group and 48.7 mo in the modified group. There were no differences in endocrine and exocrine function preservation between the two groups. The original Frey's procedure resulted in significantly betterpain relief, as shown by 5-year follow-up(P = 0.032), better emotional status(P = 0.047) and fewer fatigue symptoms(P = 0.028). When stratifying these patients by the M-ANNHEIM severity index, no impact was found on pain relief after the two types of surgery.CONCLUSION The original Frey's procedure is as safe as the modified procedure, but the former yields better pain relief. The severity of CP does not affect postoperative pain relief.

“Parenchyma transection-first”strategy is superior to“tunnel-first”strategy in robotic spleen-preserving distal pancreatectomy with conservation of splenic vessels

Background: Creating a tunnel between the pancreas and splenic vessels followed by pancreatic parenchyma transection(“tunnel-first” strategy) has long been used in spleen-preserving distal pancreatectomy(SPDP) with splenic vessel preservation(Kimura’s procedure). However, the operation space is limited in the tunnel, leading to the risks of bleeding and difficulties in suturing. We adopted the pancreatic “parenchyma transection-first” strategy to optimize Kimura’s procedure. Methods: The clinical data of consecutive patients who underwent robotic SPDP with Kimura’s procedure between January 2017 and September 2022 at our center were retrieved. The cohort was classified into a “parenchyma transection-first” strategy(P-F) group and a “tunnel-first” strategy(T-F) group and analyzed. Results: A total of 91 patients were enrolled in this cohort, with 49 in the T-F group and 42 in the P-F group. Compared with the T-F group, the P-F group had significantly shorter operative time(146.1 ± 39.2 min vs. 174.9 ± 46.6 min, P < 0.01) and lower estimated blood loss [40.0(20.0–55.0) m L vs. 50.0(20.0–100.0) m L, P = 0.03]. Failure of splenic vessel preservation occurred in 10.2% patients in the TF group and 2.4% in the P-F group( P = 0.14). The grade 3/4 complications were similar between the two groups( P = 0.57). No differences in postoperative pancreatic fistula, abdominal infection or hemorrhage were observed between the two groups. Conclusions: The pancreatic “parenchyma transection-first” strategy is safe and feasible compared with traditional “tunnel-first strategy” in SPDP with Kimura’s procedure.

Comparison between open and laparoscopic reversal of Hartmann’s procedure for diverticulitis

AIM: To compare the open and laparoscopic Hartmann’s reversal in patients first treated for complicated diverticulitis.METHODS: Forty-six consecutive patients with diverticular disease were included in this retrospective,singlecenter study of a prospectively maintained colorectal surgery database.All patients underwent conventional Hartmann’s procedures for acute complicated diverticulitis.Other indications for Hartmann’s procedures were excluded.Patients underwent open(OHR) or laparoscopic Hartmann’s reversal(LHR) between 2000 and 2010,and received the same pre-and post-operative protocols of cares.Operative variables,length of stay,short-(at 1 mo) and long-term(at 1 and 3 years) postoperative complications,and surgery-related costs were compared between groups.RESULTS: The OHR group consisted of 18 patients(13 males,mean age ± SD,61.4 ± 12.8 years),and the LHR group comprised 28 patients(16 males,mean age 54.9 ± 14.4 years).The mean operative time and the estimated blood loss were higher in the OHR group(235.8 ± 43.6 min vs 171.1 ± 27.4 min;and 301.1 ± 54.6 mL vs 225 ± 38.6 mL respectively,P = 0.001).Bowel function returned in an average of 4.3 ± 1.7 d in the OHR group,and 3 ± 1.3 d in the LHR group(P = 0.01).The length of hospital stay was significantly longer in the OHR group(11.2 ± 5.3 d vs 6.7 ± 1.9 d,P 【 0.001).The 1 mo complication rate was 33.3% in the OHR(6 wound infections) and 3.6% in the LHR group(1 hemorrhage)(P = 0.004).At 12 mo,the complication rate remained significantly higher in the OHR group(27.8% vs 10.7%,P = 0.03).The anastomotic leak and mortality rates were nil.At 3 years,no patient required re-intervention for surgical complications.The OHR procedure had significantly higher costs(+56%) compared to the LHR procedure,when combining the surgery-related costs and the length of hospital stay.CONCLUSION: LHR appears to be a safe and feasible procedure that is associated with reduced hospitality stays,complication rates,and costs compared to OHR.

Analysis of Risk Factors of Postoperative Neurological Complications in Patients with Stanford Type A Aortic Dissection Undergoing Sun’s Procedure

Objective:This study analyzed the risk factors of neurological complications in patients with Stanford type A aortic dissection after Sun’s procedure in a single-center with the purpose of improving the effects.Methods:From January 2019 to December 2020,the clinical data of 480 patients with Stanford type A aortic dissection,who were treated by Sun’s procedure in our center were retrospectively analyzed.Univariate and multivariate logistic regression analyses were used to determine the risk factors of postoperative neurological complications.According to whether there were neurological complications after surgery,they were divided into two groups:the group with complications(n=70)and the group without complications(n=410).The clinical data of the two groups were collected and compared.Results:There were 70 cases of patients with postoperative neurological complications in 480 cases.The incidence rates of temporary neurological dysfunction(TND)and permanent neurological dysfunction(PND)was 11.5%(55/480)and 3.1%(15/480),respectively.Univariate analysis showed that the age(≥70 years),stroke history,femoral artery intubation and cardiopulmonary bypass(CPB)time were associated with postoperative PND(p<0.05).Renal dysfunction,emergency surgery,postoperative hypernatremia,postoperative hyperglycemia,postoperative hypoxemia,postoperative low cardiac output syndrome,and assisted time of suction influenced the occurrence of postoperative TND(p<0.05).Multivariate logistic regression analysis showed that age(≥70 years),stroke history,femoral artery intubation and CPB time were independent risk factors for PND.Renal dysfunction,emergency surgery,postoperative hypernatremia,postoperative hyperglycemia,postoperative hypoxemia,postoperative low cardiac output syndrome,and aspiration time were independent risk factors for TND.Compared with the two groups,the hospitalization time and ICU time of the patients in the neurological complications group were significantly prolonged,and the mortality rate was significantly increased(p<0.05).Conclusion:There are many risk factors for neurological complications in patients with Stanford type A aortic dissection after surgery.With the improvement of surgical techniques,optimization of cerebral perfusion,and interventions for risk factors,Sun’s procedure remains the preferred treatment for Stanford type A aortic dissection.

Long-term survival after pancreaticoduodenectomy in patients with ductal adenocarcinoma of the pancreatic head

Background: Pancreatic ductal adenocarcinoma(PDAC) has the worst prognosis of all malignant tumors due to unavailable screening methods, late diagnosis with a low proportion of resectable tumors and resistance to systemic treatment. Complete tumor resection remains the cornerstone of modern multimodal strategies aiming at long-term survival. This study was performed to investigate the overall rate of long-term survival(LTS) and its contributing factors. Methods: This was a retrospective single-center analysis of consecutive patients undergoing pancreaticoduodenectomy(PD) for PDAC between 2007 and 2014 at the St. Josef Hospital, Ruhr University Bochum, Germany. Clinical and laboratory parameters were assessed and evaluated for prediction of LTS with Cox regression analysis. Results: The overall rate of LTS after PD for PDAC was 20.4%(34/167). Median survival was 24 months regardless of adjuvant treatment. Carbohydrate antigen 19-9 levels, tumor grade, lymph vessel invasion, perineural invasion and reduced general condition were significantly associated with LTS in univariate analysis( P<0.05). Serum levels of carbohydrate antigen 19-9, American Joint Committee on Cancer stage, tumor grade, abdominal pain, male, exocrine pancreatic insufficiency and duration of postoperative hospital stay were independent predictors of cancer survival in multivariable analysis. Conclusions: Cancer related characteristics are associated with LTS in multimodally treated patients after curative PDAC surgery.

SURGERY ON INTERCONDYLAR FRACTURE OF HUMERUS

Objective To evaluate the results of surgery on intercondylar of humerus. Methods Fifty-eight cases (26 males, 32 females), in an average age of 46. 6 (13 ~ 82 years), of intercondylar fracture of the humerus operated from September 1988 to September 1998 were followed up 29 months (8 ~ 63 months). According to the AO/MSIF classification 8, 7 and 5 cases were divided into type B1, B2 and B3 respectively while other 13, 10 and 15 patients into C1, C2 and C3 respectively. All the cases were evaluated by modified Jupiter assessment. Results Twenty-eight patients gained excellent results, while the good, fair and poor outcomes were found in twenty-two, three and five cases respectively. Conclusion Surgical treatment from posterior trans-olecranon approach with combination of internal fortion and bone graft, follwed by early active motion and adhesion relief procedure for elbow if necessary, was advocated in intercondylar fracture of humerus.

视故障为结构不确定项的鲁棒可靠跟踪控制器设计

针对含执行机构故障的凸面体不确定系统,本文基于二次型分离算子给出了一种鲁棒可靠跟踪控制器的设计方法.利用不确定系统鲁棒镇定时的拓扑分离特性,采用无损S-procedure获得二次型分离算子,对执行机构故障和系统描述矩阵进行解耦,在此基础上将故障模型的结构信息引入到控制器设计中,从而减少系统设计的保守性.并将可靠控制器设计转化为线性矩阵不等式表述的凸优化问题,利用已有的工具包对其快速求解.最后给出某飞行器纵向运动控制的设计实例,仿真结果验证了设计方法的有效性和优越性.

Laparoscopic reversal of Hartmann’s procedure:safety and feasibility

Aims:The present study aimed to compare the surgical outcomes of patients receiving laparoscopic reversal of Hartmann’s procedure(RHP)with those receiving open surgery.Methods:Records of all patients with RHP performed in our unit(including laparoscopic and open surgery)between 2000 and 2012 were retrieved.Data were retrospectively reviewed and compared.Results:Eighty-two RHPs were performed between 2000 and 2012.Thirty-five were performed with an open approach and 47 with a laparoscopic approach.Conversion rate was 28%in the laparoscopic group.There was no difference,between the two groups,in operation time or blood loss.The median length of stay was significantly shorter in the laparoscopic group(12 vs 14 days,P=0.002)and fewer patients in the laparoscopic group had complications with post-operative paralytic ileus(2 vs 17%,P=0.038).None of the patients in the laparoscopic group developed incisional hernia at the conclusion of follow-up,as opposed to five in the open group(0 vs 14%,P=0.012).Conclusion:Laparoscopic RHP is safe and feasible,with more favorable surgical outcomes,when compared with open surgery.Conversion rate is acceptable.It should be the technique of choice for patients undergoing RHP.

A Brief Review of the Second Revision of China's Criminal Procedure Law

Since the enactment of China＇s Criminal Procedure Law in 1979, China＇s criminal procedure system has undergone a process of refinement and elaboration. A relatively complete framework for the criminal procedure system has been constructed that fits in well with contemporary international thinking on criminal procedure. The Decision on Amending the Criminal Procedure Law of the People＇s Republic of China passed by the National People＇s Congress on March 14, 2012 highlights China＇s strenuous efforts in protecting human rights and promoting the modernization of the legal system. It also demonstrates the consolidation and absorption of the achievements of China＇s continuing reforms. A review of the main content of the Amendment to Criminal Procedure Law is highly significant for the further improvement of the system.

Polya's Four-Step Procedure and Creative Problem Solving

George Polya’s How to Solve it demonstrates how his procedures can be used to methodi- cally approach and solve any problem that involves thought and reasoning．In the following ex- ample we apply his four steps to problems that are not mathematical．

RETHINKING CHINESE EVIDENCE THEORIES AND RECONSTRUCTING SYSTEM OF EVIDENCE： ＂A THREAD FOR THE PEARLS OF CHINESE EVIDENCE＂

This article analyses Chinese traditional evidence theories that have evolved over a long period of time, to explore which theory, between objectivity and relevancy, best represents the basic attribute and logical thread of evidence. These theories are considered in the context of issues arising in evidential adjudication, including： the ＂Mirror of Evidence,＂ truth, the probability of proof standard, the choice between a notion of pursuing 100-percent certainty in adjudication and that wrongful acquittals are better than wrongful convictions, and the statutory proof doctrine comparedwith the system of free proof. Finally, the article presents the framework of and methods for drafting provisions of procedural evidence of the People＇s Court.

Multi-arm covariate-adaptive randomization

Simultaneously investigating multiple treatments in a single study achieves considerable efficiency in contrast to the traditional two-arm trials.Balancing treatment allocation for influential covariates has become increasingly important in today’s clinical trials.The multi-arm covariate-adaptive randomized clinical trial is one of the most powerful tools to incorporate covariate information and multiple treatments in a single study.Pocock and Simon’s procedure has been extended to the multi-arm case.However,the theoretical properties of multi-arm covariate-adaptive randomization have remained largely elusive for decades.In this paper,we propose a general framework for multi-arm covariate-adaptive designs which also includes the two-arm case,and establish the corresponding theory under widely satisfied conditions.The theoretical results provide new insights into the balance properties of covariate-adaptive randomization procedures and make foundations for most existing statistical inferences under two-arm covariate-adaptive randomization.Furthermore,these open a door to study the theoretical properties of statistical inferences for clinical trials based on multi-arm covariateadaptive randomization procedures.