Short-term and Long-term Outcomes of Robotic Enucleation of Tumors Located in the Pancreatic Head and Uncinate Process.

OBJECTIVE: To assess short-term and long-term outcomes following robotic enucleation (REn) of tumors in the proximal pancreas. BACKGROUND: Despite the advantages of preserving function via pancreatic enucleation, controversies persist, since this can be associated with severe complications, such as clinically relevant postoperative pancreatic fistula, especially when performed near the main pancreatic duct. The safety and efficacy of REn in this context remain largely unknown. METHODS: A retrospective analysis was performed of all patients who underwent REn for benign and low-grade malignant neoplasms in the pancreatic head and uncinate process between January 2005 and December 2021. Clinicopathologic, perioperative, and long-term outcomes were compared with a similar open enucleation (OEn) group. RESULTS: Of 146 patients, 92 underwent REn with a zero conversion-to-open rate. REn was superior to OEn in terms of shorter operative time (90.0 minutes vs 120.0 minutes, P<0.001), decreased blood loss (20.0 mL vs 100.0 min, P=0.001), and lower clinically relevant postoperative pancreatic fistula rate (43.5% vs 61.1%, P=0.040). Bile leakage rate, major morbidity, 90-day mortality, and length of hospital stay were comparable between groups. No post-REn grade C POPF or grade IV/V complication was identified. Subgroup analyses for uncinate process tumors and proximity to the main pancreatic duct did not demonstrate inferior postoperative outcomes. In a median follow-up period of 50 months, REn outcomes were comparable to OEn regarding recurrence rate and pancreatic endocrine or exocrine function. CONCLUSIONS: REn for pancreatic head and uncinate process tumors improved clinically relevant outcomes without increased major complications compared to OEn, while demonstrating comparable long-term oncological and functional outcomes.

Efficient automated high dynamic range 3D measurement via deep reinforcement learning.

High dynamic range 3D measurement technology, utilizing multiple exposures, is pivotal in industrial metrology. However, selecting the optimal exposure sequence to balance measurement efficiency and quality remains challenging. This study reinterprets this challenge as a Markov decision problem and presents an innovative exposure selection method rooted in deep reinforcement learning. Our approach's foundation is the exposure image prediction network (EIPN), designed to predict images under specific exposures, thereby simulating a virtual environment. Concurrently, we establish a reward function that amalgamates considerations of exposure number, exposure time, coverage, and accuracy, providing a comprehensive task definition and precise feedback. Building upon these foundational elements, the exposure selection network (ESN) emerges as the centerpiece of our strategy, acting decisively as an agent to derive the optimal exposure sequence selection. Experiments prove that the proposed method can obtain similar coverage (0.997 vs. 1) and precision (0.0263 mm vs. 0.0230 mm) with fewer exposures (generally 4) compared to the results of 20 exposures.

A rationally designed nuclei-targeting FAPI 04-based molecular probe with enhanced tumor uptake for PET/CT and fluorescence imaging.

PURPOSE: Fibroblast activation protein inhibitor (FAPI) -based probes have been widely studied in the diagnosis of various malignant tumors with positron emission tomography/computed tomography (PET/CT). However, current imaging studies of FAPI-based probes face challenges in rapid clearance rate and potential false-negative results. Furthermore, FAPI has been rarely explored in optical imaging. Considering this, further modifications are imperative to improve the properties of FAPI-based probes to address existing limitations and broaden their application scenarios. In this study, we rationally introduced methylene blue (MB) to FAPIs, thereby imparting nuclei-targeting and fluorescence imaging capabilities to the probes. Furthermore, we evaluated the added value of FAPI-based fluorescence imaging to traditional PET/CT, exploring the potential application of FAPI-based probes in intraoperative fluorescence imaging. METHODS: A new FAPI-based probe, namely NOTA-FAPI-MB, was designed for both PET/CT and fluorescence imaging by conjugation of MB. The targeting efficacy of the probe was evaluated on fibroblast activation protein (FAP)-transfected cell line and human primary cancer-associated fibroblasts (CAFs). Subsequently, PET/CT and fluorescence imaging were conducted on tumor-bearing mice. The tumor detection and boundary delineation were assessed by fluorescence imaging of tissues from hepatocellular carcinoma (HCC) patients. RESULTS: NOTA-FAPI-MB demonstrated exceptional targeting ability towards FAP-transfected cells and CAFs in comparison to NOTA-FAPI. This benefit arises from the cationic methylene blue (MB) affinity for anionic nucleic acids. PET/CT imaging of tumor-bearing mice revealed significantly higher tumor uptake of [18F]F-NOTA-FAPI-MB (standard uptake value of 2.20 ± 0.31) compared to [18F]F-FDG (standard uptake value of 1.66 ± 0.14). In vivo fluorescence imaging indicated prolonged retention at the tumor site, with retention lasting up to 24 h. In addition, the fluorescent probes enabled more precise lesion detection and tumor margin delineation than clinically used indocyanine green (ICG), achieving a 100.0% (6/6) tumor-positive rate for NOTA-FAPI-MB while 33.3% (2/6) for ICG. These findings highlighted the potential of NOTA-FAPI-MB in guiding intraoperative surgical procedures. CONCLUSIONS: The NOTA-FAPI-MB was successfully synthesized, in which FAPI and MB simultaneously contributed to the targeting effect. Notably, the nuclear delivery mechanism of the probes improved intracellular retention time and targeting efficacy, broadening the imaging time window for fluorescence imaging. In vivo PET/CT demonstrated favorable performance of NOTA-FAPI-MB compared to [18F]F-FDG. This study highlights the significance of fluorescence imaging as an adjunct technique to PET/CT. Furthermore, the encouraging results obtained from the imaging of human HCC tissues hold promise for the potential application of NOTA-FAPI-MB in intraoperative fluorescent surgery guidance within clinical settings.

Chiral Iridium-Based TLD-1433 Analogues: Exploration of Enantiomer-Dependent Behavior in Photodynamic Cancer Therapy.

Metallodrug-based photodynamic therapy (PDT) agents have demonstrated significant superiority against cancers, while their different chirality-induced biological activities remain largely unexplored. In this work, we successfully developed a pair of enantiopure mononuclear Ir(III)-based TLD-1433 analogues, Δ-Ir-3T and Λ-Ir-3T, and their enantiomer-dependent anticancer behaviors were investigated. Photophysical measurements revealed that they display high photostability and chemical stability, strong absorption at 400 nm with high molar extinction coefficients (ε = 5.03 × 104 M-1 cm-1), and good 1O2 relative quantum yields (ΦΔ ≈ 47%). Δ- and Λ-Ir-3T showed potent efficacy against MCF-7 cancer cells, with a photocytotoxicity index of ≤44 238. This impressive result, to the best of our knowledge, represents the highest value among reported mononuclear Ir(III)-based PDT agents. Remarkably, Λ-Ir-3T tended to be more potent than Δ-Ir-3T when tested against SK-MEL-28, HepG2, and LO2 cells, with consistent results across multiple test repetitions.

Modifying Proton Relay into Bioinspired Dye-based Coordination Polymer for Photocatalytic Proton-Coupled Electron Transfer.

Proton-coupled electron transfer (PCET) imparts an energetic advantage over solo electron transfer in activating inert substances. Natural PCET enzyme catalysis generally requires tripartite preorganization of proton relay, substrate-bound active center, and redox mediator, making the processes efficient and precluding side reactions. Inspired by this, a heterogeneous photocatalytic PCET system was established to achieve higher PCET driving forces by modifying proton relays into anthraquinone-based anionic coordination polymers. The proximally separated proton relays and photoredox-mediating anthraquinone moiety allowed pre-assembly of inert substrate between them, merging proton and electron into unsaturated bond by photoreductive PCET, which enhanced reaction kinetics than the counter catalyst without proton relay. This photocatalytic PCET method was applied to a broad-scoped reduction of aryl ketones, unsaturated carbonyls, and aromatic compounds. The distinctive regioselectivities for the reduction of isoquinoline derivatives were found to occur on the carbon-ring sides. PCET-hydrogenated radical intermediate of quinoline could be trapped by alkene for proton relay-assisted Minisci addition, forming the pharmaceutical aza-acenaphthene scaffold within one step. When using heteroatom(X)-H/C-H compounds as proton-electron donors, this protocol could activate these inert bonds through photooxidative PCET to afford radicals and trap them by electron-deficient unsaturated compounds, furnishing the direct X-H/C-H functionalization.

Harnessing Radicals in Confined Supramolecular Environments Made Possible by MOFs.

Researching and utilizing radical intermediates in organic synthetic chemistry have innovated discoveries in methodology and theory. Reactions concerning free radical species opened new pathways beyond the frame of the two-electron mechanism while commonly characterized as rampant processes lacking selectivity. As a result, research in this field has always focused on the controllable generation of radical species and determining factors of selectivity. Metal-organic frameworks (MOFs) have emerged as compelling candidates as catalysts in radical chemistry. From a catalytic point of view, the porous nature of MOFs entails an inner phase for the reaction that could offer possibilities for the regulation of reactivity and selectivity. From a material science perspecti ve, MOFs are organic-inorganic hybrid materials that integrate functional units in organic compounds and complex forms in the tunable long-ranged periodic structure. In this account, we summarized our progress in the application of MOFs in radical chemistry in three parts: (1) The generation of radical species; (2) The weak interactions and site selectivity; (3) Regio- and stereo-selectivity. The unique role of MOFs play in these paradigms is demonstrated in a supramolecular narrative through the analyses of the multi-constituent collaboration within the MOF and the interactions between MOFs and the intermediates during the reactions.

Hypoxia-induced long non-coding RNA LINC00460 promotes p53 mediated proliferation and metastasis of pancreatic cancer by regulating the miR-4689/UBE2V1 axis and sequestering USP10.

Long non-coding RNAs are considered to be key regulatory factors of oncogenesis and tumor progression. It is reported that LINC00460 plays the role of oncogene in some tumors. However, LINC00460's role and mechanism of action in pancreatic cancer have not yet been fully elucidated. We identified LINC00460 by analyzing data from the Gene Expression Omnibus database. The role of LINC00460 in proliferation and metastasis was examined using CCK8, colony formation, wound healing, and transwell assays. The potential mechanisms of LINC00460 in regulating mRNA levels were elucidated by RNA pull-down, RNA immunoprecipitation, Chromatin immunoprecipitation, Co-immunoprecipitation, and Immunofluorescence assays. The results showed that LINC00460 was upregulated in pancreatic cancer cells and tissues. Highly expressed LINC00460 is significantly related to short survival of pancreatic cancer patients. Inhibition of LINC00460 attenuated pancreatic cancer cell proliferation and metastasis, whereas its overexpression reversed this effect. Mechanically, LINC00460 is induced by hypoxia, through binding of the hypoxia-inducible factor 1-α in the promoter region of LINC00460. Furthermore, LINC00460 functioned as an miR-4689 sponge to regulate the downstream target gene UBE2V1, enhancing the stability of mutant p53 in pancreatic cancer cells. LINC00460 also further promotes pancreatic cancer development by sequestering USP10, a cytoplasmic ubiquitin-specific protease that deubiquitinates p53 and enhances its stability. Collectively, our study demonstrated that LINC00460 is a hypoxia-induced lncRNA that plays the role of oncogene in pancreatic cancer by modulating the miR-4689/UBE2V1 axis, sequestering USP10, and ultimately enhancing the stability of mutant p53.

Chromatographic and mass spectrometric technologies for chemical analysis of Euodiae fructus: A review.

INTRODUCTION: Euodiae fructus, also known as Evodiae fructus, is a popular Chinese herbal medicine derived from the dried, nearly ripe fruits of Tetradium ruticarpum (A. Juss.) T. G. Hartley. The main bioactive constituents of Euodiae fructus are alkaloids, limonoids, flavonoids, and anthraquinones. The contents of these compounds vary greatly between different plant species, geographic locations, and harvest times, which thus affect the therapeutic effects. OBJECTIVES: We aimed to summarize the chromatographic and mass spectrometric technologies applied for chemical analysis and quality evaluation of Euodiae fructus. Moreover, we aimed to emphasize the diverse soft ionization techniques and mass analyzers of LC-MS methods for assessment of Euodiae fructus. METHODOLOGY: A literature study was carried out by retrieving articles published between January 1988 and December 2021 from well-known databases, including PubMed, ASC, Elsevier, ScienceDirect, J·STAGE, Thieme, Taylor & Francis, Springer Link, Wiley Online Library, and CNKI. The chemical analysis methods were described in several categories in accordance with the used analytical techniques, including thin-layer chromatography (TLC), high-performance liquid chromatography (HPLC), high-performance liquid chromatography-mass spectrometry (HPLC-MS), gas chromatography-mass spectrometry (GC-MS), capillary electrophoresis (CE), and counter-current chromatography (CCC). RESULTS: This review systematically summarizes the achievements in chemical analysis and quality evaluation of Euodiae fructus published in over three decades, covering the various chromatographic and mass spectrometric technologies applied for identification and quantification of phytochemical constituents. CONCLUSION: The summary serves as an important basis for future phytochemical research and implementation of quality control methods in order to ensure the efficacy and safety of Euodiae fructus.

A Diode-Like Dye-Cu Anisotropic Junction in a Coordination Polymer as a Logic State Ratchet for Intratumor Redox Photomodulation.

Redox logic materials offer new avenues to modulate intracellular pathologic redox environment area-specifically, but the unambiguity of redox logic states and their unidirectional and repetitive switchability are challenging to realize. By merging a bistable diisophthalic phenazine dye ligand with CuII salt, a multistable coordination polymer (CP) was constructed, of which the dye-Cu anisotropic junction achieved the diode-like unidirectional electron transfer and logic state ratchet for the first time. Radical cationic CP maintained OFF status with low toxicity in healthy tissues, but was reduced to the neutral SERVO state by the overexpressed glutathione (GSH) in hypoxic tumors. After photoirradiation, the stabilized charge-separated ON status promoted photo-Fenton reaction for reactive oxygen species (ROS) signal transduction, and simultaneously recovered the initial state for catalytic signal amplification of ROS, furnishing intratumor redox photomodulation for therapy.

Three-Component Multiblock 1D Supramolecular Copolymers of Ir(III) Complexes with Controllable Sequences.

Multicomponent supramolecular block copolymers (BCPs) have attracted much attention due to their potential functionalities, but examples of three-component supramolecular BCPs are rare. Herein, we report the synthesis of three-component multiblock 1D supramolecular copolymers of Ir(III) complexes 1-3 by a sequential seeded supramolecular polymerization approach. Precise control over the kinetically trapped species via the pathway complexity of the monomers is the key to the successful synthesis of BCPs with up to 9 blocks. Furthermore, 5-block BCPs with different sequences could be synthesized by changing the addition order of the kinetic species during a sequentially seeded process. The corresponding heterogeneous nucleation-elongation process has been confirmed by the UV/Vis absorption spectra, and each segment of the multiblock copolymers could be characterized by both TEM and SEM. Interestingly, the energy transfer leads to weakened emission of 1-terminated and enhanced emission of 3-terminated BCPs. This study will be an important step in advancing the synthesis and properties of three-component BCPs.

Supramolecular Copolymers Under Kinetic, Thermodynamic, or Pathway-Switching Control.

Supramolecular copolymers have attracted much attention due to their potential functionalities. However, the co-assembly strategies to construct co-assemblies of small molecules with well-defined sequence structures are still limited, especially for more complex crystalline block co-assemblies. Herein, we target this challenge by designing IrIII complexes 1 and 2, which possess unique self-assembly pathways and are capable of forming crystalline assemblies in aqueous systems. Specifically, block and random co-assemblies of 1 and 2 can be synthesized by kinetic and thermodynamic control, respectively. Meanwhile, by adjusting the water content to orthogonalize the on-pathway and the off-pathway, an unprecedented pathway-switching approach is realized to synthesize block and random co-assemblies. By coupling the kinetic pathways, the present co-assembly strategies are expected to pave the way for the synthesis of crystalline co-assemblies of small molecules and the construction of organic heterostructures.

Robotic versus open pancreaticoduodenectomy with vascular resection for pancreatic ductal adenocarcinoma: surgical and oncological outcomes from pilot experience.

PURPOSE: Venous resection and reconstruction (VR) is a feasible surgical technique to achieve optimal outcomes in selected patients with pancreatic ductal adenocarcinoma (PDAC) who undergo open pancreaticoduodenectomy (OPD). However, data regarding patient outcomes in patients who undergo VR in robotic-assisted pancreaticoduodenectomy (RPD) are scarce. METHODS: All patients with a diagnosis of PDAC who underwent upfront open or robotic pancreatoduodenectomy with VR in a high-volume institution for pancreatic surgery between 2011 and 2019 were retrospectively reviewed. Perioperative and long-term outcomes were compared between the RPD and OPD cohorts. RESULTS: A total of 84 patients were included in the final analysis, 14 patients underwent RPD with VR and 70 who had OPD with VR. Reconstructed venous patency, postoperative 30-day morbidity, and 90-day mortality were comparable; however, lymph node resection rates were lower in the RPC cohort (p = 0.029). No difference was identified in 3-year survival rates between the two groups (34.0% versus 25.7% respectively, p = 0.667). CONCLUSION: RPD with VR is a feasible approach for patients with PDAC and venous invasion. Further studies are needed to assess long-term outcomes compared to the open approach.

Learning Curve From 450 Cases of Robot-Assisted Pancreaticoduocectomy in a High-Volume Pancreatic Center: Optimization of Operative Procedure and a Retrospective Study.

OBJECTIVE: We aimed to describe our experience and the learning curve of 450 cases of robot-assisted pancreaticoduodenectomy (RPD) and optimize the surgical process so that our findings can be useful for surgeons starting to perform RPD. SUMMARY BACKGROUND DATA: Robotic surgical systems were first introduced 20 years ago. Pancreaticoduodenectomy (PD) is a challenging surgery because of its technical difficulty. RPD may overcome some of these difficulties. METHODS: The medical records of 450 patients who underwent RPD between May 2010 and December 2018 at the Shanghai Ruijin Hospital were retrospectively analyzed. Operative times and estimated blood loss (EBL) were analyzed and the learning curve was determined. A cumulative sum (CUSUM) analysis was used to identify the inflexion points. Other postoperative outcomes, postoperative complications, and long-term follow-up were also analyzed. RESULTS: Operative time improved graduallyovertimefrom405.4 ±â€Š112.9 minutes (case 1-50) to 273.6 ±â€Š70 minutes (case 301-350) (P < 0.001). EBL improved from 410 ±â€Š563.5 mL (case 1-50) to 149.0 ±â€Š103.3 mL (case 351-400) (P< 0.001). According to the CUSUM curve, there were 3 phases in the RPD learning curve. The inflexion points were around cases 100 and 250. The incidence of pancreatic leak in the last 350 cases was significantly lower than that in the first 100 cases (30.0% vs 15.1%, P = 0.003). CONCLUSIONS: RPD is safe and feasible for selected patients. Operative and oncologic outcomes were much improved after experience of 250 cases. Our optimization of the surgical process may have also contributed to this. Future prospective and randomized studies are needed to confirm our results.

Robotic-assisted versus open distal pancreatectomy for benign and low-grade malignant pancreatic tumors: a propensity score-matched study.

BACKGROUND: This study aimed to compare the short-term outcomes of open and robotic-assisted distal pancreatectomy (ODP and RDP) for benign and low-grade malignant tumors. METHODS: The patients who underwent RDP and ODP for benign or low-grade malignant pancreatic tumors at our center were included. After PSM at a 1:1 ratio, the perioperative variations in the two cohorts were compared. RESULTS: After 1:1 PSM, 219 cases of RDP and ODP were recorded. The RDP cohort showed advantages in the operative duration [120 (90-150) min vs 175 (130-210) min, P < 0.001], estimated blood loss [50 (30-175) ml vs 200 (100-300) ml, P < 0.001], spleen preservation rate (63.5% vs 26.5%, P < 0.001), infection rate (4.6% vs 12.3%, P = 0.006), and gastrointestinal function recovery [3 (2-4) vs. 3 (3-5), P = 0.019]. There were no significant differences in postoperative pancreatic fistula, postoperative hemorrhage, and delayed gastric emptying. Multivariate analysis showed that RDP (HR 0.24; 95% CI 0.16-0.36, P < 0.001), age (HR 1.02; 95% CI 1.00-1.03, P = 0.033), tumor size (HR 1.28; 95% CI 1.17-1.40, P < 0.001), pathological inflammatory neoplasm type (HR 5.12; 95% CI 2.22-11.81, P < 0.001), and estimated blood loss (HR 1.003; 95% CI 1.001-1.004, P < 0.001) were independent predictors of spleen preservation; RDP (HR 0.27; 95% CI 0.17-0.43, P < 0.001), age (HR 1.02; 95% CI 1.00-1.03, P = 0.022), elevated CA 19-9 level (HR 2.55; 95% CI 1.02-6.39, P = 0.046), tumor size (HR 1.44; 95% CI 1.29-1.61, P < 0.001), pathological inflammatory neoplasm type (HR 4.48; 95% CI 1.69-11.85, P = 0.003), and estimated blood loss (HR 1.003; 95% CI 1.001-1.004, P < 0.001) were independent predictors of spleen preservation with the Kimura technique. CONCLUSION: RDP has advantages in the operative time, blood loss, spleen preservation, infection rate, and gastrointestinal function recovery over ODP in treating benign and low-grade malignant pancreatic tumors. The robotic-assisted approach was an independent predictor of spleen preservation and use of the Kimura technique.

Oncological outcomes of robotic-assisted versus open pancreatoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score-matched analysis.

BACKGROUND: Robotic-assisted minimally invasive surgery is associated with worse oncologic outcomes for some but not other types of cancers. We conducted a propensity score-matched analysis to compare oncologic outcomes of robotic-assisted laparoscopic (RPD) vs. open pancreatoduodenectomy (OPD) for pancreatic ductal adenocarcinoma (PDAC). METHODS: Treatment-naïve PDAC patients undergoing either RPD or OPD at our hospital between January 2013 and December 2017 were included. Propensity score matching was conducted at a ratio of 1:2. The primary outcome was disease-free survival (DFS) and overall survival (OS). RESULTS: A total of 672 cases were identified. The propensity score-matched cohort included 105 patients receiving RPD and 210 patients receiving OPD. The 2 groups did not differ in the number of retrieved lymph nodes [11 (7-16) vs. 11 (6-17), P = 0.622] and R0 resection rate (88.6% vs. 89.0%, P = 0.899). There was no statistically significant difference in median DFS (14 [95% CI 11-22] vs. 12 [95% CI 10-14] months (HR 0.94; 95% CI 0.87-1.50; log-rank P = 0.345) and median OS (27 [95% CI 22-35] vs. 20 [95% CI 18-24] months (HR 0.77; 95% CI 0.57-1.04; log-rank P = 0.087) between the two groups. Multivariate COX analysis showed that RPD was not an independent predictor of DFS (HR 0.90; 95% CI 0.68-1.19, P = 0.456) or OS (HR 0.77; 95% CI 0.57-1.05, P = 0.094). CONCLUSION: Comparable DFS and OS were observed between patients receiving RPD and OPD. This preliminary finding requires further confirmation with prospective randomized controlled trials.

PPTFH: Robust Local Descriptor Based on Point-Pair Transformation Features for 3D Surface Matching.

Three-dimensional feature description for a local surface is a core technology in 3D computer vision. Existing descriptors perform poorly in terms of distinctiveness and robustness owing to noise, mesh decimation, clutter, and occlusion in real scenes. In this paper, we propose a 3D local surface descriptor using point-pair transformation feature histograms (PPTFHs) to address these challenges. The generation process of the PPTFH descriptor consists of three steps. First, a simple but efficient strategy is introduced to partition the point-pair sets on the local surface into four subsets. Then, three feature histograms corresponding to each point-pair subset are generated by the point-pair transformation features, which are computed using the proposed Darboux frame. Finally, all the feature histograms of the four subsets are concatenated into a vector to generate the overall PPTFH descriptor. The performance of the PPTFH descriptor is evaluated on several popular benchmark datasets, and the results demonstrate that the PPTFH descriptor achieves superior performance in terms of descriptiveness and robustness compared with state-of-the-art algorithms. The benefits of the PPTFH descriptor for 3D surface matching are demonstrated by the results obtained from five benchmark datasets.

Learning curve of robot-assisted middle pancreatectomy (RMP): experience of the first 100 cases from a high-volume pancreatic center in China.

OBJECTIVE: Middle pancreatectomy (MP) is safe and feasible in patients with benign or low-grade malignant tumors located at the neck or proximal body of the pancreas. As a tissue-sparing operation, MP can preserve normal pancreatic function and reduce the risk of postoperative endocrine and exocrine insufficiency. However, the morbidity, especially the postoperative pancreatic fistula (POPF) rate, remains high. A robot-assisted surgical system may provide patients with less trauma; however, there are few reports on robot-assisted middle pancreatectomy (RMP). We describe the experience of RMP at our center to illustrate the learning curve (LC). METHODS: From August 2010 to July 2017, 100 patients underwent RMP in the Pancreatic Disease Center of Shanghai Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine. Patient characteristics, operative outcomes, and oncological outcomes were collected and analyzed. The CUSUM curve was analyzed according to operative time and estimated blood loss (EBL) and was used to describe the LC and identify the flexion points. RESULTS: Among the 100 patients who underwent RMP in our hospital, the mean age was 47.5 ± 14.2 years, and 69 patients were female. From the CUSUM curve, we found two flexion points: cases 12 and 44. After 44 cases, the rate of improvement was much faster. We separated the patients into two groups based on the LC (cases 1-44 and cases 45-100). There were significant improvements in operative time (173.1 ± 44.7 min vs. 137.3 ± 30.1 min, p < 0.001) and EBL (103.4 ± 90.0 ml vs. 69.3 ± 53.9 ml, p = 0.021). The overall POPF rate was 32% (32/100), while the incidence rate of biochemical leakage was 14% (14/100). However, there was no significant difference in the risk of POPF or other complications between the two groups. The postoperative length of stay (LOS) was also not different. The 90-day mortality rate was 1%. From our long-term follow-up, pancreatic function was preserved in most patients, with only three cases of endocrine insufficiency and two cases of exocrine insufficiency. CONCLUSION: RMP was helpful and a good choice for the selected patients. PF was the main complication and has not been improved until now. There were two flexion points in the LC at cases 12 and 44. More cases are needed to gain more experience. A larger sample size and prospective studies are needed to verify the advantage of RMP.

[The Efficacy of 17 Cases of Pancreaticoduodenectomy Combined with Vascular Resection and Reconstruction by Using Robotic Operation System (with Video)].

OBJECTIVE: To explore the clinical efficacy of pancreaticoduodenectomy (PD) combined with vascular resection and reconstruction under robotic surgery system in the treatment of borderline resectable pancreatic cancer. METHODS: The clinical data of 17 patients with borderline resectable pancreatic cancer who underwent PD combined with vascular resection and reconstruction (see the Video 1 in Supplemental Contents, http://ykxb.scu.edu.cn/article/doi/10.12182/20200760202) under robotic surgery system between August 2011 and September 2018 was analyzed retrospectively. RESULTS: There were 4 cases required conversion because of serious tumor invasion and soft pancreas texture, the other 13 cases were successfully completed. 16 cases (94%) achieved margin-negative resection (R0 resection), 14 cases combined with vein resection, and 3 cases combined with arterial resection. The mean operation time was (401±170) min, the mean blood loss was (647±345) mL, the mean postoperative length of hospital stay was (20±8) d. There was no perioperative death. Postoperative pathology findings and follow-up outcomes were as follows: 1 patient was diagnosed as intraductal papillary mucinous neoplasm (IPMN) and 1 patient was diagnosed as pancreatic neuroendocrine tumors (PNET) (Grade 1), 8 patients with pancreatic ductal adenocarcinoma (PDAC). 1 patient with pancreatic neuroendocrine carcinoma (PNEC) died because of tumor recurrence and metastasis during the follow-up period, the median (Min-Max) survival time was 12 (8-26) months. 5 patients with PDAC and 1 patient with malignant IPMN were currently in the follow-up period. CONCLUSION: It is safe and feasible to perform RPD with vascular resection and reconstruction. The patient's condition should be fully evaluated before surgery to select the most appropriate treatment.

Comparison of Radical Antegrade Modular Pancreatosplenectomy with Standard Retrograde Pancreatosplenectomy for Left-Sided Pancreatic Cancer: A Meta-Analysis and Experience of a Single Center.

BACKGROUND Radical antegrade modular pancreatosplenectomy (RAMPS) has been reported as a modified surgical technique used to achieve better margin resection and to retrieve more lymph nodes compared with standard retrograde pancreatosplenectomy (SRPS). MATERIAL AND METHODS A systematic literature review was performed to identify studies published in PubMed, EmBase, and Web of Science. Hazard ratio (HR), risk ratio (RR), weighted mean difference (WMD), and their 95% confidence intervals (95% CIs) were used as effect measures. In addition, the clinical data of 27 patients in our center were collected and retrospectively analyzed. RESULTS Seven studies containing 474 patients were finally enrolled in this meta-analysis. The pooled results showed that the RAMPS group had a better overall survival (OS) compared with the SRPS group (HR=0.65, 95% CI: 0.43-0.99, P=0.046; I²=41.8%, P=0.143). Significantly more lymph nodes were harvested in the RAMPS group compared with in the SRPS group (WMD=4.74, 95% CI: 0.36-9.12, P=0.034). Recurrence rate (RR=0.8, 95% CI: 0.66-0.98, P=0.028) and blood loss (WMD=-153.19 ml, 95% CI: -303.95 to -2.42, P=0.046) were both significantly reduced in the RAMPS group. Retrospective analysis results showed that only significantly more harvested lymph nodes were noted in the RAMPS group compared with the SRPS group (7.55±0.91 vs. 2.81±0.73, P=0.001). CONCLUSIONS Our study suggests that RAMPS has better prognosis and surgical outcomes than SRPS for left-sided pancreatic cancer. Nevertheless, more high-quality clinical trials are required to validate the result.

Predicting Selection Preference of Robotic Pancreaticoduodenectomy (RPD) in a Chinese Single Center Population: Development and Assessment of a New Predictive Nomogram.

BACKGROUND Robotic pancreaticoduodenectomy (RPD) is a novel type of minimally invasive surgery to treat tumors located at the head of the pancreas. This study aimed to construct a novel prediction model for predicting selection preference for RPD in a Chinese single medical center population. MATERIAL AND METHODS The clinical data from 451 pancreatic ductal adenocarcinoma patients were collected and analyzed from January 2013 to December 2016. Twenty-three items affecting clinical strategies were optimized by LASSO (least absolute shrinkage and selection operator) regression analysis and then were incorporated in multivariable logistic regression analysis. C-index was used for evaluating the discriminative ability. Decision curve was applied to determine clinical application of this model and the calibration of this nomogram was evaluated by calibration plot. The model was internally validated through bootstrapping validation. RESULTS Clinicopathological factors included in the model were age, history of diabetes mellitus, history of hypertension, history of heart, brain and kidney disease, history of abdominal surgery, symptoms (jaundice, accidental discovery and weight loss), anemia, elevated carcinoembryonic antigen (CEA), smoking, alcohol intake, American Society of Anesthesiologists (ASA) scores, vascular invasion, overweight, preoperative lymph node metastasis and tumor size >3.5 cm. A C-index of 0.831 indicated good discrimination and calibration of this model. Interval validation generated an acceptable C-index of 0.787. When surgical approach was determined at the threshold of preference possibility less than 63%, decision curve analysis indicated that this model had good clinical application value in this range. CONCLUSIONS This new nomogram could be conveniently used to predict the selection preference of robotic surgery for patients with pancreatic head cancer.