Robotic versus laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: A propensity score-matched analysis

Background: Minimally invasive surgery is becoming increasingly popular in the field of pancreatic surgery. However, there are few studies of robotic distal pancreatectomy(RDP) for pancreatic ductal adenocarcinoma(PDAC). This study aimed to investigate the efficacy and feasibility of RDP for PDAC. Methods: Patients who underwent RDP or laparoscopic distal pancreatectomy(LDP) for PDAC between January 2015 and September 2020 were reviewed. Propensity score matching analyses were performed. Results: Of the 335 patients included in the study, 24 underwent RDP and 311 underwent LDP. A total of 21 RDP patients were matched 1:1 with LDP patients. RDP was associated with longer operative time(209.7 vs. 163.2 min;P = 0.003), lower open conversion rate(0% vs. 4.8%;P < 0.001), higher cost(15 722 vs. 12 699 dollars;P = 0.003), and a higher rate of achievement of an R0 resection margin(90.5% vs. 61.9%;P = 0.042). However, postoperative pancreatic fistula grade B or C showed no significant intergroup difference(9.5% vs. 9.5%). The median disease-free survival(34.5 vs. 17.3 months;P = 0.588) and overall survival(37.7 vs. 21.9 months;P = 0.171) were comparable between the groups. Conclusions: RDP is associated with longer operative time, a higher cost of surgery, and a higher likelihood of achieving R0 margins than LDP.

Spleen-preserving distal pancreatectomy from multi-port to reducedport surgery approach

BACKGROUND Minimally invasive pancreatic surgery via the multi-port approach has become a primary surgical method for distal pancreatectomy(DP)due to its advantages of lower wound pain and superior cosmetic results.Some studies have applied reduced-port techniques for DP in an attempt to enhance cosmetic outcomes due to the minimally invasive effects.Numerous recent review studies have compared multi-port laparoscopic DP(LDP)and multi-port robotic DP(RDP);most of these studies concluded multi-port RDP is more beneficial than multi-port LDP for spleen preservation.However,there have been no comprehensive reviews of the value of reduced-port LDP and reduced-port RDP.AIM To search for and review the studies on spleen preservation and the clinical outcomes of minimally invasive DP that compared reduced-port DP surgery with multi-port DP surgery.METHODS The PubMed medical database was searched for articles published between 2013 and 2022.The search terms were implemented using the following Boolean search algorithm:(“distal pancreatectomy”OR“left pancreatectomy”OR“peripheral pancreatic resection”)AND(“reduced-port”OR“single-site”OR“single-port”OR“dual-incision”OR“single-incision”)AND(“spleen-preserving”OR“spleen preservation”OR“splenic preservation”).A literature review was conducted to identify studies that compared the perioperative outcomes of reduced-port LDP and reduced-port RDP.RESULTS Fifteen articles published in the period from 2013 to 2022 were retrieved using three groups of search terms.Two studies were added after manually searching the related papers.Finally,10 papers were selected after removing case reports(n=3),non-English language papers(n=1),technique papers(n=1),reviews(n=1),and animal studies(n=1).The common items were defined as items reported in more than five papers,and data on these common items were extracted from all papers.The ten studies included a total of 337 patients(females/males:231/106)who underwent DP.In total,166 patients(females/males,106/60)received multi-port LDP,126(females/males,90/36)received reduced-port LDP,and 45(females/males,35/10)received reduced-port RDP.CONCLUSION Reduced-port RDP leads to a lower intraoperative blood loss,a lower postoperative pancreatic fistula rate,and shorter hospital stay and follow-up duration,but has a lower spleen preservation rate.

Distal pancreatectomy with or without radical approach, vascular resections and splenectomy: Easier does not always mean easy

Because distal pancreatectomy(DP)has no reconstructive steps and less frequent vascular involvement,it is thought to be the easier counterpart of pancreaticoduodenectomy.This procedure has a high surgical risk and the overall incidences of perioperative morbidity(mainly pancreatic fistula),and mortality are still high,in addition to the challenges that accompany delayed access to adjuvant therapies(if any)and prolonged impairment of daily activities.Moreover,surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes.From this perspective,new surgical approaches,and aggressive techniques,such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection,could lead to improved survival in those affected by more locally advanced tumors.Conversely,minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress.The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications,length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy.Because a dedicated multidisciplinary team is crucial to pancreatic surgery,hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign,borderline,and malignant diseases of the pancreas.The purpose of this review is to examine the state of the art in distal pancreatectomies,with a special focus on minimally invasive approaches and oncological-directed techniques.The widespread reproducibility,cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.

Laparoscopic distal pancreatectomy is as safe and feasible as open procedure:A meta-analysis

AIM:To evaluate the feasibility and safety of laparoscopic distal pancreatectomy(LDP) compared with open distal pancreatectomy(ODP).METHODS:Meta-analysis was performed using the databases,including PubMed,the Cochrane Central Register of Controlled Trials,Web of Science and BIOSIS Previews.Articles should contain quantitative data of the comparison of LDP and ODP.Each article was reviewed by two authors.Indices of operative time,spleen-preserving rate,time to fluid intake,ratio of malignant tumors,postoperative hospital stay,incidence rate of pancreatic fistula and overall morbidity rate were analyzed.RESULTS:Nine articles with 1341 patients who underwent pancreatectomy met the inclusion criteria.LDP was performed in 501(37.4%) patients,while ODP was performed in 840(62.6%) patients.There were significant differences in the operative time,time to fluid intake,postoperative hospital stay and spleen-preserving rate between LDP and ODP.There was no difference between the two groups in pancreatic fistula rate [random effects model,risk ratio(RR) 0.996(0.663,1.494),P = 0.983,I2 = 28.4%] and overall morbidity rate [random effects model,RR 0.81(0.596,1.101),P = 0.178,I2 = 55.6%].CONCLUSION:LDP has the advantages of shorter hospital stay and operative time,more rapid recovery and higher spleen-preserving rate as compared with ODP.

Risk factors associated with pancreatic fistula after distal pancreatectomy, which technique of pancreatic stump closure is more beneficial?

AIM: To identify risk factors related to pancreatic fistula in patients undergoing distal pancreatectomy (DP) and to determine the effectiveness of using a stapled and a sutured closed of pancreatic stump. METHODS: Sixty-four patients underwent DP during a 10-year period. Information regarding diagnosis, operative details, and perioperative morbidity or mortality was collected. Eight risk factors were examined. RESULTS: Indications for DP included primary pancreatic disease (n = 38, 59%) and non-pancreatic malignancy (n = 26, 41%). Postoperative mortality and morbidity rates were 1.5% and 37% respectively; one patient died due to sepsis and two patients required a reoperation due to postoperative bleeding. Pancreatic fistula was developed in 14 patients (22%); 4 of fistulas were classified as Grade A, 9 as Grade B and only 1 as Grade C. Incidence of pancreatic fistula rate was significantly associated with four risk factors: pathology, use of prophylactic octreotide therapy, concomitant splenectomy, and texture of pancreatic parenchyma. The role that technique (either stapler or suture) of pancreatic stump closure plays in the development of pancreatic leak remains unclear. CONCLUSION: The pancreatic fistula rate after DP is 22%. This is reduced for patients with non-pancreatic malignancy, fibrotic pancreatic tissue, postoperative prophylactic octreotide therapy and concomitant splenectomy.

Laparoscopic spleen-preserving distal pancreatectomy for pancreatic neoplasms:A retrospective study

AIM: To describe the clinical characteristics, technical procedures, and outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for benign and malignant pancreatic neoplasms.

Pancreatic Castleman disease treated with laparoscopic distal pancreatectomy

BACKGROUND: Castleman disease is an uncommon lympho-proliferative disorder most frequently occurring in the mediastinum. Abdominal forms are less frequent, with pancreatic localization of the disease in particular being extremely rare. Only seventeen cases have been described in the world literature. METHOD: This report describes an interesting and unusual case of pancreatic Castleman disease treated with laparoscopic resection. RESULTS: A 48-year-old woman presented with epigastric pain. CT scan showed a well-encapsulated mass on the ventral border of the pancreas. Endosonography with fine needle aspiration biopsy was performed. Biopsy showed lymphoid elements and structures of a normal lymph node. The patient was treated with laparoscopic distal pancreatectomy. The pancreas was transected with a Ligasure device and the pancreatic stump was secured with a manual suture. One year after surgery the patient was complaint-free and showed no signs of recurrence of the disease. CONCLUSIONS: Laparoscopic distal pancreatectomy is a feasible and safe method for the treatment of lesions in the body and tail of the pancreas. Transection of the pancreas with a Ligasure device offers the advantages of low bleeding and low risk of pancreatic fistula.

Minimally invasive spleen-preserving distal pancreatectomy: Does splenic vessel preservation have better postoperative outcomes? A systematic review and meta-analysis

BACKGROUND： Minimally invasive spleen-preserving distal pancreatectomy （SPDP） can be performed with either splenic vessel preservation （SVP） or resection [Warshaw procedure （WP）]. The aim of this study was to evaluate the postoperative clinical outcomes of patients undergoing both methods. DATA SOURCES： Database search of PubMed, Embase, Scopus, Cochrane, and Google Scholar was performed （2000-2014）; key bibliographies were reviewed. Qualified studies compar- ing patients undergoing SPDP with either SVP or WP, and as- sessing postoperative complications were included. Calculated pooled risk ratio （RR） with the corresponding 95% confidence interval （CI） by random effects methods were used in the meta-analyses. RESULTS： The search yielded 215 studies, of which only 14 observational studies met our selection criteria. The studies included 943 patients in total; 652 （69%） underwent SVP and 291 （31%） underwent WP. Overall, there was a lower incidence of splenic infarction （RR=0.17; 95% Ch 0.09-0.33; P〈0.001）, gastric varices （RR=0.16; 95% Ch 0.05-0.51; P=0.002）, and intra/postoperative splenectomy （RR=0.20; 95% Ch 0.08-0.49; P〈0.001） in the SVP group. There was no difference in in- cidence of pancreatic fistula （WP vs SVP, 23.6% vs 22.9%;P=0.37）, length of hospital stay, operative time or blood loss. There was moderate cross-study heterogeneity. CONCLUSIONS： SVP is a safe, efficient and feasible technique that may be used to preserve the spleen. WP may be more suit- able for large tumors dose to the splenic hilum or those associ- ated with splenomegaly. Randomized clinical trials are justified to examine the long-term benefits of SVP-SPDP.

Successful treatment of a pancreatic schwannoma by spleen-preserving distal pancreatectomy

Schwannomas are neurogenic tumors that arise from the neural sheaths of peripheral nerves. These tumors can be located in any area of the human body; the most common locations are the head, neck, trunk and extremities. Pancreatic schwannomas are very rare. Over the past 40 years, only 67 cases of pancreatic schwannomas have been reported in the English literature. Here we present a case of pancreatic schwannoma in a 62-year-old male. The tumor was revealed by ultrasound and computed tomography in the neck and body of the pancreas. An accurate diagnosis was difficult to obtain preoperatively. The patient consented to the performance of a laparotomy, and the mass was found in the neck and body of the pancreas and successfully treated using a spleen-preserving distal pancreatectomy with splenic artery and vein preservation. The procedure has only been reported in one other case of pancreatic schwannoma; here we present the second reported case. Macroscopically, the tumor was well circumscribed, gray-white in color and 3.3 cm x 2.8 cm in size. Microscopically, the tumor cells were spindle-shaped and had a palisading arrangement with no atypia, which are results compatible with a benign tumor. Both hypercellular and hypocellular areas were visible. Immunohistochemically, the tumor cells were strongly positive for S-100 protein. The tumor was definitively diagnosed as a schwannoma of the pancreatic neck and body. The patient was followed for 72 mo and has been doing well without any complications.

Laparoscopic distal pancreatectomy: Up-to-date and literature review

Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffu- sion. Additional researches are necessary to determine the best technique to improve the procedure results.

Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas

Since the first report on laparoscopic distal pancreatectomy (LDP) appeared in the 1990s, the procedure has been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Many earlier publications have shown LDP to be a good alternative to open distal pancreatectomy for benign lesions, although this has never been studied in a prospective, randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as well established. The purpose of this review is to evaluate the current evidence for LDP in cases of pancreatic adenocarcinoma. We conducted a review of English language publications reporting LDP results between 1990 and 2013. All studies reporting results in patients with histologically proven pancreatic adenocarcinoma were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pancreatic adenocarcinoma (potential double publications were not eliminated). Most LDP procedures are performed in selected cases and generally involve smaller tumors than open distal pancreatectomy (ODP) procedures. Some of the papers report unselected cases and include procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.

Application of retrograde distal pancreatectomy

BACKGROUND: Since conventional methods are difficult to deal with pancreatic tumors close to the portal veins, we investigated the feasibility and norms for retrograde distal pancreatectomy by cutting the neck of the pancreas first. METHOD: The clinical data and surgical procedures of retrograde distal pancreatectomy given to 11 patients from July 2001 to June 2007 were analyzed. RESULTS: All 11 operations were completed successfully. The mean time of the operation was 143 71 minutes. The mean volume of hemorrhage was 239 ml. The mean time of hospitalization was 12 +/- 4.2 days. No blood transfusion was needed during the operation, and all patients had a good postoperative recovery. No neopathy of diabetes mellitus, pancreatic fistula or other complications occurred after the operation. The follow-up of all patients (4-60 months) showed that 3 patients survived for 14, 16 and 33 months, respectively, and the other patients are still alive. CONCLUSIONS: Retrograde distal pancreatectomy is useful for exposing the portal and superior mesenteric veins while avoiding operative injury. Interception of the blood supply of the spleen helps to reduce the volume of hemorrhage, while making the operation easier and the operative time short. It is advantageous for tumor resection of the body of the pancreas near the portal veins.

Ligamentum teres hepatis patch enhances the healing of pancreatic fistula after distal pancreatectomy

Pancreatic fistula is one of the most common complications after the distal pancreatectomy.Many methods have been tried to solve the problem,but no one is optimal,especially for the soft pancreatic stump cases.This study used ligamentum teres hepatis as a patch to cover the pancreatic stump.Between October 2010 and December 2012,seventyseven patients who had undergone distal pancreatectomy with a soft pancreatic stump were divided into two groups:group A(n=39,patients received conventional ligated main pancreatic duct method)and group B(n=38,patients underwent a coverage procedure).Patients in group A had a longer recovery from postoperative pancreatic fistula than those in group B(16.4±3.5 vs 10.8±1.6 days,P【0.05).The coverage procedure with ligamentum teres hepatis is a safe,effective and convenient method for patients with a soft pancreas remnant during distal pancreatectomy.

Successful treatment of pancreatic accessory splenic hamartoma by laparoscopic spleen-preserving distal pancreatectomy:A case report

BACKGROUND Pancreatic accessory spleen(PAS)is an uncommon congenital abnormality of the spleen.Spleen hamartoma(SH)is also rare.Moreover,hamartoma in the PAS has not been reported thus far.We report the first case here.CASE SUMMARY A 26-year-old male presented with a one-month history of left upper quadrant abdominal pain,and computerized tomography(CT)examination suggested a mass in the pancreas tail.The patient then attended our hospital for diagnosis and treatment.Ultrasonography,CT,and magnetic resonance imaging revealed a solid mass with cystic degeneration growing from the tail of the pancreas.The tumor marker carbohydrate antigen 19-9(CA19-9)increased to 96.7 U/mL(normal range 0-37 U/mL).An epidermoid cyst in a PAS was considered preoperatively.However,a malignant tumor cannot be ruled out.We performed laparoscopic surgery,and two pancreatic masses were found growing from the pancreatic tail.The two masses were so closely connected that preoperative imaging examinations suggested only one mass.We carefully isolated the masses from the splenic artery and vein.A laparoscopic spleen-preserving distal pancreatectomy was successfully performed.On pathological examination,the masses were well-defined,homogeneous red-tan,4×3,and 4.5×1.5 in size,respectively.One of them was cystically degenerated.On microscopical examination,the mass contained unorganized small slit-like vascular channels enclosing red blood cells and lined with plump endothelial cells.No area of cytologic atypia was identified.Focal lymphoid aggregates were found in the intravascular areas.White pulp or fibrosis was not observed.The final diagnosis was pancreatic accessory SH with cystic degeneration.After the operation,CA19-9 was reduced to normal.The patient recovered well,and the 34-mo follow-up period was uneventful.CONCLUSION Here,we report the first case of pancreatic accessory SH.A laparoscopic spleen-preserving distal pancreatectomy was successfully performed.The patient recovered well and had a good prognosis.

Male gender and increased body mass index independently predicts clinically relevant morbidity after spleen-preserving distal pancreatectomy

AIM To identify risk factors for clinically relevant complications after spleen-preserving distal pancreatectomy(SPDP). No previous studies explored potential predictors of morbidity after SPDP.METHODS The data of 41 patients who underwent a SPDP in a single surgical center between 2000 and 2015 were retrospectively reviewed from a prospectively maintained electronic database established in our Department of Surgery. The database included demographic, clinical, bioumoral, pathological, intraoperative and postoperative parameters. Uni-and multivariate ana-lyses were performed to assess potential predictors of clinically relevant morbidity. Postoperative morbidity was defined as in-hospital complications and mortality was assessed at 90 d. Clinically relevant morbidity was defined as complication ≥ grade 2 Dindo.RESULTS Overall morbidity rate was 34.1%(14 patients): grade Ⅰ(6 patients, 14.6%), grade Ⅱ(2 patients, 4.8%), grade Ⅲa(1 patient, 2.4%), and grade Ⅲb(5 patients, 12.2%). A number of 5 patients(12.2%) required re-laparotomy for postoperative complications. There was no postoperative mortality. Thus, at least one clinically relevant complication occurred in 8 patients(19.5%). Univariate analysis identified male gender(P = 0.034), increased body mass index(P = 0.002) and neuroendocrine pathology(P = 0.013) as statistically significant risk factors. Multivariate analysis identified male gender [odds ratio(OR): 1.29, 95%CI: 1.07-1.55, P = 0.005] and increased body mass index(OR: 23.18, 95%CI: 1.72-310.96, P = 0.018) as the only independent risk factors of clinically relevant morbidity after SPDP.CONCLUSION Male gender and increased body mass index are independently associated with increased risk of clinically relevant morbidity after SPDP. These findings may assist a surgeon in clinical decision-making to better select patients suitable for SPDP.

Laparoscopic distal pancreatectomy in Italy:a systematic review and meta-analysis

BACKGROUND： The use of laparoscopic distal pancreatectomy（LDP） increased in the past twenty years but the real diffusion of this technique is still unknown as well as the type of centers（high or low volume） in which this procedure is more frequently performed.DATA SOURCE： A systematic review was performed to evaluate the frequency of LDP in Italy and to compare indications and results in high volume centers（HVCs） and in low volume centers（LVCs）.RESULTS： From 95 potentially relevant citations identified, only5 studies were included. A total of 125 subjects were analyzed, of whom 95（76.0%） were from HVCs and 30（24.0%） from LVCs.The mean number of LDPs performed per year was 6.5. The mean number of patients who underwent LDP per year was 8.8in HVCs and 3.0 in LVCs（P0.001）. The most frequent lesions operated on in HVCs were cystic tumors（62.1%, P0.001） while,in LVCs, solid neoplasms（76.7%, P0.001）. In HVCs, malignant neoplasms were treated with LDP less frequently than in LVCs（17.9% vs 50.0%, P〈0.001）. Splenectomy was performed for non-oncologic reason frequenter in HVCs than in LVCs（70.2%vs 25.0%, P0.004）. The length of stay was shorter in HVCs than in LVCs（7.5 vs 11.3, P0.001）. No differences were found regarding age, gender, ductal adenocarcinoma treated, operative time, conversion, morbidity, postoperative pancreatic fistula,reoperation and margin status.CONCLUSIONS： LDPs were frequently performed in Italy.The ＂HVC approach＂ is characterized by a careful selection of patients undergoing LDP. The ＂LVC approach＂ is based on the hypothesis that LDPs are equivalent both in short-term and long-term results to laparotomic approach. These data are not conclusive and they point out the need for a national register of laparoscopic pancreatectomy.

Updated outcomes using clockwise technique for laparoscopic distal pancreatectomy:Optimal treatment of benign and malignant disease of the left pancreas

Background:Laparoscopic distal pancreatectomy(LDP)has become the preferred approach for surgical management of left sided pancreas pathology.Our institution previously published its experience with distal pancreatectomies using a clockwise technique with good outcomes.We now reexamine our outcomes across a longer time interval.Methods:From August 2008 to November 2020,364 patients underwent LDP by hepatobiliary surgeons(HA and JS).All procedures were performed using the same clockwise approach,which includes the stepwise slow compression technique.Retrospective descriptive analysis of patient demographic,clinical,operative,and pathologic data was conducted.Results:Of the 364 patients who underwent LDP using this technique,clinically significant postoperative pancreatic fistula(POPF)was noted in 26(7.1%)patients,while major morbidity and mortality were reported in 9.9%and 0.3%,respectively.Hand-assisted method was required for 18(4.9%)patients and unplanned conversion in 20(5.5%)patients.In a subset analysis of patients with pancreatic adenocarcinoma(n¼90),POPF was noted in 13(14.4%),with minor complications occurring in 34.4%and major morbidity in 14.4%.Conclusion:LDP with a clockwise approach for dissection,combined with the stepwise slow compression technique results in excellent outcomes,with even lower POPF rates than originally reported.Subset analysis of patients with pancreatic adenocarcinoma shows acceptable perioperative outcomes with this technique.

To drain or not to drain after distal pancreatectomy: reflexions on the PANDORINA trial

We read with great interest the PANDORINA study(1).This international multicenter(mostly from the Netherlands)randomized controlled trial aimed at determining whether omitting drainage after distal pancreatectomy(DP)was equivalent in terms of complications to systematic drainage placement.The primary outcome was the occurrence of severe complications at 90 days defined as Dindo-Clavien grade≥3.The main secondary outcome was the occurrence of grade B–C postoperative pancreatic fistula(POPF)at 90 days.For both outcomes,the non-inferiority threshold was set at 8%.Randomization was performed intraoperatively,stratified by annual center volume(high volume defined as DP≥40/year)and the risk of POPF according to the distal fistula risk score(D-FRS)combining pancreas thickness(high risk,>19 mm)and main pancreatic duct diameter(high risk,>3 mm)measured both at the isthmus(2).

A novel clinical model for risk prediction and stratification of new-onset diabetes mellitus after distal pancreatectomy

Background:The incidence of new-onset diabetes mellitus(NODM)after distal pancreatectomy(DP)remains high.Few studies have focused on NODM in patients with pancreatic benign or low-grade malignant lesions(PBLML).This study aimed to develop and validate an effective clinical model for risk prediction and stratification of NODM after DP in patients with PBLML.Methods:A follow-up survey was conducted to investigate NODM in patients without preoperative DM who underwent DP.Four hundred and forty-eight patients from Peking Union Medical College Hospital(PUMCH)and 178 from Guangdong Provincial People’s Hospital(GDPH)met the inclusion criteria.They constituted the training cohort and the validation cohort,respectively.Univariate and multivariate Cox regression,as well as least absolute shrinkage and selection operator(LASSO)analyses,were used to identify the independent risk factors.The nomogram was constructed and verified.Concordance index(C-index),receiver operating characteristic(ROC)curve,calibration curves,and decision curve analysis(DCA)were applied to assess its predictive performance and clinical utility.Accordingly,the optimal cut-off point was determined by maximally selected rank statistics method,and the cumulative risk curves for the high-and low-risk populations were plotted to evaluate the discrimination ability of the nomogram.Results:The median follow-up duration was 42.8 months in the PUMCH cohort and 42.9 months in the GDPH cohort.The postoperative cumulative 5-year incidences of DM were 29.1%and 22.1%,respectively.Age,body mass index(BMI),length of pancreatic resection,intraoperative blood loss,and concomitant splenectomy were significant risk factors.The nomogram demonstrated significant predictive utility for post-pancreatectomy DM.The C-indexes of the nomogram were 0.739 and 0.719 in the training and validation cohorts,respectively.ROC curves demonstrated the predictive accuracy of the nomogram,and the calibration curves revealed that prediction results were in general agreement with the actual results.The considerable clinical applicability of the nomogram was certified by DCA.The optimal cut-off point for Background:The incidence of new-onset diabetes mellitus(NODM)after distal pancreatectomy(DP)remains high.Few studies have focused on NODM in patients with pancreatic benign or low-grade malignant lesions(PBLML).This study aimed to develop and validate an effective clinical model for risk prediction and stratification of NODM after DP in patients with PBLML.Methods:A follow-up survey was conducted to investigate NODM in patients without preoperative DM who underwent DP.Four hundred and forty-eight patients from Peking Union Medical College Hospital(PUMCH)and 178 from Guangdong Provincial People’s Hospital(GDPH)met the inclusion criteria.They constituted the training cohort and the validation cohort,respectively.Univariate and multivariate Cox regression,as well as least absolute shrinkage and selection operator(LASSO)analyses,were used to identify the independent risk factors.The nomogram was constructed and verified.Concordance index(C-index),receiver operating characteristic(ROC)curve,calibration curves,and decision curve analysis(DCA)were applied to assess its predictive performance and clinical utility.Accordingly,the optimal cut-off point was determined by maximally selected rank statistics method,and the cumulative risk curves for the high-and low-risk populations were plotted to evaluate the discrimination ability of the nomogram.Results:The median follow-up duration was 42.8 months in the PUMCH cohort and 42.9 months in the GDPH cohort.The postoperative cumulative 5-year incidences of DM were 29.1%and 22.1%,respectively.Age,body mass index(BMI),length of pancreatic resection,intraoperative blood loss,and concomitant splenectomy were significant risk factors.The nomogram demonstrated significant predictive utility for post-pancreatectomy DM.The C-indexes of the nomogram were 0.739 and 0.719 in the training and validation cohorts,respectively.ROC curves demonstrated the predictive accuracy of the nomogram,and the calibration curves revealed that prediction results were in general agreement with the actual results.The considerable clinical applicability of the nomogram was certified by DCA.The optimal cut-off point for risk prediction value was 2.88, and the cumulative risk curves of each cohort showed significant differences between the high- and low-risk groups. Conclusions: The nomogram could predict and identify the NODM risk population, and provide guidance to physicians in monitoring and controlling blood glucose levels in PBLML patients after DP.

Optimizing prediction models for pancreatic fistula after pancreatectomy:Current status and future perspectives

Postoperative pancreatic fistula(POPF)is a frequent complication after pancre-atectomy,leading to increased morbidity and mortality.Optimizing prediction models for POPF has emerged as a critical focus in surgical research.Although over sixty models following pancreaticoduodenectomy,predominantly reliant on a variety of clinical,surgical,and radiological parameters,have been documented,their predictive accuracy remains suboptimal in external validation and across diverse populations.As models after distal pancreatectomy continue to be pro-gressively reported,their external validation is eagerly anticipated.Conversely,POPF prediction after central pancreatectomy is in its nascent stage,warranting urgent need for further development and validation.The potential of machine learning and big data analytics offers promising prospects for enhancing the accuracy of prediction models by incorporating an extensive array of variables and optimizing algorithm performance.Moreover,there is potential for the development of personalized prediction models based on patient-or pancreas-specific factors and postoperative serum or drain fluid biomarkers to improve accuracy in identifying individuals at risk of POPF.In the future,prospective multicenter studies and the integration of novel imaging technologies,such as artificial intelligence-based radiomics,may further refine predictive models.Addressing these issues is anticipated to revolutionize risk stratification,clinical decision-making,and postoperative management in patients undergoing pancre-atectomy.