Application of the superior mesenteric artery-first approach in laparoscopic pancreatoduodenectomy: A literature review.

Background: Laparoscopic pancreaticoduodenectomy (LPD) is a complicated surgical procedure that has recently been performed safely. A superior mesenteric artery (SMA)-first approach can allow complete mesopancreas resection, maximizing surgical margins and R0 resection rates. Therefore, the SMA-first approach is recommended. This review is a literature summary of recent updates of the SMA approaches for LPD and informs clinical practice of the advantages of its various approach. Methods: A systematic literature search was performed on the PubMed (MEDLINE) database using truncated word searches and medical subject headings to identify all pertinent published studies. Results: After searching PubMed, 303 studies were identified and reviewed, of which 25 described the SMA-first approach, including the anterior, posterior, right, and left approaches, fully described in 5, 6, 13, and 6 articles, respectively. Conclusions: The SMA-first approach is the standard surgical technique for LPD. This review summarized each SMA-first approach's distinct advantages and indications.

Effect of Laparoscopic and Open Pancreaticoduodenectomy for Pancreatic or Periampullary Tumors: Three-year Follow-up of a Randomized Clinical Trial.

OBJECTIVE: This study aimed to estimate whether the potential short-term advantages of laparoscopic pancreaticoduodenectomy (LPD) could allow patients to recover in a more timely manner and achieve better long-term survival than with open pancreaticoduodenectomy (OPD) in patients with pancreatic or periampullary tumors. BACKGROUND: LPD has been demonstrated to be feasible and may have several potential advantages over OPD in terms of shorter hospital stay and accelerated recovery than OPD. METHODS: This noninferiority, open-label, randomized clinical trial was conducted in 14 centers in China. The initial trial included 656 eligible patients with pancreatic or periampullary tumors enrolled from May 18, 2018, to December 19, 2019. The participants were randomized preoperatively in a 1:1 ratio to undergo either LPD (n=328) or OPD (n=328). The 3-year overall survival (OS), quality of life, which was assessed using the 3-level version of the European Quality of Life-5 Dimensions, depression, and other outcomes were evaluated. RESULTS: Data from 656 patients [328 men (69.9%); mean (SD) age: 56.2 (10.7) years] who underwent pancreaticoduodenectomy were analyzed. For malignancies, the 3-year OS rates were 59.1% and 54.3% in the LPD and OPD groups, respectively ( P =0.33, hazard ratio: 1.16, 95% CI: 0.86-1.56). The 3-year OS rates for others were 81.3% and 85.6% in the LPD and OPD groups, respectively ( P =0.40, hazard ratio: 0.70, 95% CI: 0.30-1.63). No significant differences were observed in quality of life, depression and other outcomes between the 2 groups. CONCLUSION: In patients with pancreatic or periampullary tumors, LPD performed by experienced surgeons resulted in a similar 3-year OS compared with OPD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03138213.

Outcomes of laparoscopic pancreaticoduodenectomy using a modified technique：346 cases from a single center.

PURPOSE: To study the outcomes of laparoscopic pancreaticoduodenectomy (LPD) using a modified technique. METHODS: Our center used priority approach of uncinate process and artery in the pancreatectomy and duct to mucosa pancreaticojejunostomy with a single stitch in the pancreaticojejunostomy. Herein, we retrospectively reviewed 346 cases of LPD using modified techniques. Basic characteristics, preoperative outcomes, factors associated with unfavorable postoperative outcome, and mortality of patients undergoing LPD were collected and analyzed. RESULTS: The average operative time was 259.31 (35-425) min. The mean duration of pancreaticojejunostomy anastomosis was 31.97 (16-90) min. The mean intraoperative blood loss was 101.76 (0-1200) ml by estimation. Postoperative complications included 14 cases (4.1%) of bile leakage, 9 cases (2.6%) of delayed gastric emptying, 26 cases (7.5%) of postoperative bleeding, 34 cases (9.9%) of organ space infection, 17 cases (4.9%) of pulmonary infection, and 50 cases (14.5%) of POPF. Three factors including postoperative bleeding (OR = 3.502; P = 0.033), positive lymph node (OR = 3.296; P < 0.001), and postoperative chemotherapy (OR = 0.241; P = 0.008) were significantly associated with death of LPD. CONCLUSIONS: The modified technique for LPD presents safety and reliability. Postoperative bleeding and positive lymph node may be associated with worse overall survival, and postoperative chemotherapy may be associated with better overall survival.

Development of a nomogram for predicting the high-risk groups of solid-pseudopapillary neoplasms of the pancreas.

Background: Solid pseudopapillary neoplasms (SPNs) of the pancreas are indolent rare tumors with malignant potential. The risk factors associated with the malignant behavior of SPNs are still unclear. Methods: A retrospective analysis of patients with SPNs who underwent surgical treatment in the First Hospital of Jilin University from January 2010 to January 2022 was conducted. The clinical baseline data, pathology, imaging, and laboratory indicators of the patients were analyzed by univariate and multivariate logistic regression to identify the independent risk factors associated with the high-risk groups, and a predictive model was established in the form of a nomogram. Results: In multivariate analysis, clinical symptoms (P < 0.001), unclear tumor margins (P = 0.001), incomplete tumor capsules (P = 0.005), maximum tumor diameters ≥ 7.2 cm (P = 0.003), and prognostic nutritional index values < 47.45 (P = 0.007) were independent risk factor for SPNs with high-risk groups. A nomogram model was successfully established to predict high-risk groups of SPNs. The area under the receiver operating characteristic curve was 0.856. The calibration prediction curve was in good agreement with the standard curve. Conclusion: The nomogram model based on clinical symptoms, inflammatory markers, and imaging features had a high application value in the preoperative prediction of the high-risk groups of SPNs. A novel nomogram of the affiliated hospital of Jilin University-SPNs risk model was proposed for routine application to guide the patient counseling in clinical practice.

Perioperative omega-3 fatty acids for liver surgery: A meta-analysis of randomized controlled trials.

INTRODUCTION: The effect of perioperative omega-3 fatty acids for liver surgery remained controversial. We conducted a systematic review and meta-analysis to explore the influence of omega-3 fatty acids versus placebo in patients undergoing liver surgery. METHODS: We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through May 2020, and included randomized controlled trials (RCTs) assessing the effect of omega-3 fatty acids versus placebo for liver surgery. This meta-analysis was performed using the random-effect model. RESULTS: Five RCTs were included in the meta-analysis. Overall, compared with control group for liver surgery, omega-3 fatty acids were associated with substantially reduced incidence of infection (odd ratio [OR]=0.56; 95% confidence interval [CI] =0.34-0.91; P = .02), but revealed no remarkable influence on complications (OR = 0.60; 95% CI = 0.29-1.24; P = .17), mortality (OR = 0.76; 95% CI = 0.06-9.37; P = .83), liver failure (OR = 0.72; 95% CI = 0.10 to 5.00; P = 0.74), biliary leakage (OR=1.24; 95% CI = 0.41 to 3.76; P = .70), bleeding (OR = 1.76; 95% CI = 0.63-4.95; P = .28), or ileus (OR = 0.39; 95% CI = 0.07-2.05; P = .27). CONCLUSION: Perioperative omega-3 fatty acids may be beneficial to reduce the incidence of infection after liver surgery.

Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: a multicentre, open-label, randomised controlled trial.

BACKGROUND: The benefit and safety of laparoscopic pancreatoduodenectomy (LPD) for the treatment of pancreatic or periampullary tumours remain controversial. Studies have shown that the learning curve plays an important role in LPD, yet there are no randomised studies on LPD after the surgeons have surmounted the learning curve. The aim of this trial was to compare the outcomes of open pancreatoduodenectomy (OPD) with those of LPD, when performed by experienced surgeons. METHODS: In this multicentre, open-label, randomised controlled trial done in 14 Chinese medical centres, we recruited patients aged 18-75 years with a benign, premalignant, or malignant indication for pancreatoduodenectomy. Eligible patients were randomly assigned (1:1) to undergo either LPD or OPD. Randomisation was centralised via a computer-generated system that used a block size of four. The patients and surgeons were unmasked to study group, whereas the data collectors, outcome assessors, and data analysts were masked. LPD and OPD were performed by experienced surgeons who had already done at least 104 LPD operations. The primary outcome was the postoperative length of stay. The criteria for discharge were based on functional recovery, and analyses were done on a modified intention-to-treat basis (ie, including patients who had a pancreatoduodenectomy regardless of whether the operation was the one they were assigned to). This trial is registered with Clinicaltrials.gov, number NCT03138213. FINDINGS: Between May 18, 2018, and Dec 19, 2019, we assessed 762 patients for eligibility, of whom 656 were randomly assigned to either the LPD group (n=328) or the OPD group (n=328). 31 patients in each group were excluded and 80 patients crossed over (33 from LPD to OPD, 47 from OPD to LPD). In the modified intention-to-treat analysis (297 patients in the LPD group and 297 patients in the OPD group), the postoperative length of stay was significantly shorter for patients in the LPD group than for patients in the OPD group (median 15·0 days [95% CI 14·0-16·0] vs 16·0 days [15·0-17·0]; p=0·02). 90-day mortality was similar in both groups (five [2%] of 297 patients in the LPD group vs six [2%] of 297 in the OPD group, risk ratio [RR] 0·83 [95% CI 0·26-2·70]; p=0·76). The incidence rate of serious postoperative morbidities (Clavien-Dindo grade of at least 3) was not significantly different in the two groups (85 [29%] of 297 patients in the LPD group vs 69 [23%] of 297 patients in OPD group, RR 1·23 [95% CI 0·94-1·62]; p=0·13). The comprehensive complication index score was not significantly different between the two groups (median score 8·7 [IQR 0·0-26·2] vs 0·0 [0·0-20·9]; p=0·06). INTERPRETATION: In highly experienced hands, LPD is a safe and feasible procedure. It was associated with a shorter length of stay and similar short-term morbidity and mortality rates to OPD. Nonetheless, the clinical benefit of LPD compared with OPD was marginal despite extensive procedural expertise. Future research should focus on identifying the populations that will benefit from LPD. FUNDING: National Natural Science Foundation of China and Tongji Hospital, Huazhong University of Science and Technology, China.

T-DM1-induced thrombocytopenia in breast cancer patients: New perspectives.

PURPOSE: Human epidermal growth factor receptor 2 (HER2) is overexpressed in 15-20% of patients with breast cancer. HER2 overexpression is the result of a genetic alteration and this marker is associated with poor clinical outcomes. HER2-targeted therapy can significantly improve the prognosis of patients with either early or advanced HER2-positive breast cancer. One such therapy is the antibody drug conjugate (ADC) trastuzumab emtansine (T-DM1), a combination of trastuzumab and the cytotoxic antimicrotubule agent DM1. After T-DM1 binds HER2, DM1 is subsequently released into the cell. T-DM1 is generally well tolerated and has a relatively low incidence of adverse events. However, there are clinical concerns regarding T-DM1-induced high-grade thrombocytopenia. METHODS: Here, we summarize the incidence of thrombocytopenia from several clinical trials and review experimental studies to explore the causes for T-DM1-induced thrombocytopenia. Progress in several other ADCs targeting HER2-positive breast cancer was also reviewed. CONCLUSIONS: We conclude that T-DM1 uptake by megakaryocytes occurs through either Fcγ receptor binding or through pinocytosis, and we suggest several methods through which these processes could be interrupted to potentially improve the clinical safety of T-DM1. More generally, we recommend that toxicity should be carefully addressed during the development of ADCs.

Application of Laparoscopic Pancreatoduodenectomy in Elderly Patients.

Background: Pancreaticoduodenectomy (PD) involves complicated surgical procedures and is associated with high postoperative mortality. PD can be performed using laparoscopy; however, there is a lack of evidence on laparoscopic PD (LPD) outcomes in elderly patients. Therefore, this study aimed to compare LPD outcomes in elderly patients with those in patients aged <65 years and assess elderly outcomes according to the LPD surgical learning curve. Materials and Methods: In this retrospective study, medical records of 75 elderly patients (Group A) and 225 patients aged <65 years (Group B) were reviewed. Preoperative and postoperative data, as well as oncologic outcomes, were collected. To assess the effect of the surgical learning curve on outcomes of elderly patients, patients were equally divided into four phases, based on the number of surgeries performed at the study site. Results: The mean preoperative physical status score was significantly higher in Group A than in Group B (z = 5.222, P < .001), indicating higher disease severity. There were no significant differences in operative time, intraoperative blood loss, vascular reconstruction rate, or intensive care unit (ICU) stay between the groups. The blood transfusion rate (χ2 = 4.301, P = .038) and length of postoperative hospital stay (z = 2.386, P = .017) were significantly higher in Group A than in Group B. The surgical resection margins and the number of lymph nodes harvested did not differ between the two groups; however, a significant difference was observed in pathological results. In assessing the surgical learning curve, the pairwise comparison of means showed that the operation times in phases 3 and 4 were shorter than that in phase 1 (P < .05) and differences in nasogastric tube removal time between the four groups were statistically significant (H = 15.390, P = .002). Conclusions: Advanced age alone should not be a contraindication for LPD, since outcomes for elderly patients who have undergone LPD are similar to those for younger patients.

Endoscopic Nasogallbladder Drainage Combined with Laparoscopic Surgery for Type I Mirizzi Syndrome with Acute Cholecystitis: A Case Series Report.

OBJECTIVE: To investigate the safety and feasibility of endoscopic nasogallbladder drainage (ENGBD) combined with laparoscopic surgery for Mirizzi syndrome type I with acute cholecystitis. METHODS: An analysis of 4 patients with type I Mirizzi syndrome with acute cholecystitis admitted to the First Hospital of Jilin University. RESULTS: The patients underwent ENGBD, and laparoscopic surgery was evaluated postoperatively. All four patients successfully recovered from this combined surgical approach. CONCLUSION: The combination of ENGBD and laparoscopic surgery is safe and feasible for the treatment of patients with type I Mirizzi syndrome accompanied by acute cholecystitis. This approach may reduce the traumatic stress on patients and is worthy of widespread implementation.

Application of Biomarkers for the Prediction and Diagnosis of Bone Metastasis in Breast Cancer.

The most common metastatic site of breast cancer is the bone. Metastatic bone disease can alter the integrity of the bone and cause serious complications, thereby greatly reducing health-related quality of life and leading to high medical costs. Although diagnostic methods and treatments for bone metastases (BM) are improving, some patients with early breast cancer who are at high risk of BM are not diagnosed early enough, leading to delayed intervention. Moreover, whole-body scintigraphy cannot easily distinguish BM from non-malignant bone diseases. To circumvent these issues, specific gene and protein biomarkers are being investigated for their potential to predict, diagnose, and evaluate breast cancer prognosis. In this review, we summarized the current biomarkers associated with BM in breast cancer and their role in clinical applications to assist in the diagnosis and treatment of BM in the future.

Glissonean Pedicle Transection with Hepatic Vein Exclusion for Hepatocellular Carcinoma: A Comparative Study with the Pringle Maneuver.

Background: Appropriate surgical techniques to control hemorrhage and retain residual liver function are key to treatment success for hepatocellular carcinoma (HCC). This study aimed to evaluate the clinical application of Glissonean pedicle transection with hepatic vein exclusion (HVE). Materials and Methods: Between April 2013 and December 2015, 50 patients underwent surgical resection for HCC and were randomly allocated to receive Glissonean pedicle transection with HVE (Glisson group, n = 25) or Pringle maneuver with intermittent clamping (Pringle group, n = 25). Intraoperative blood loss, blood transfusion, operation time, positive surgical margins, complications (bile leakage, hemorrhage, and ascites), and hospital stay were compared between groups, along with the alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TB) levels at baseline and postoperative days 1, 3, and 7. Results: The operation time and range of hepatic resection were comparable between groups. Although both groups had similar preoperative ALT, AST, and TB levels, these levels on postoperative days 1, 3, and 7 were significantly lower in the Glisson group than in the Pringle group (all P < .01). Compared with the Pringle group, the Glisson group had a significantly lower intraoperative blood loss (P < .001), a lower blood transfusion rate (P = .017), lower incidence rates of postoperative hemorrhage (P = .030) and ascites (P = .024), a lower positive surgical margin rate (P = .017), and a shorter length of hospital stay (P < .001). Conclusions: Glissonean pedicle transection with HVE is a safe, simple, and effective procedure for hepatic resection.

PES1 In Liver Cancer: A Prognostic Biomarker With Tumorigenic Roles.

PURPOSE: Liver cancer has a high incidence of mortality. DNA replication and posttranscriptional modifications play important roles in the development of liver cancer. Pescadillo (PES1) is a nuclear protein that is involved in embryonic development, ribosome synthesis, DNA replication, and cell cycle progression. Recently, abnormal PES1 expression was reported in several tumors, including neuroblastoma, colon cancer, gastric cancer, and breast cancer. Based on bio-informatic analysis, cell experiments and animal models, the aim of this study is to investigate the expression patterns and specific roles of PES1 in liver cancer. PATIENTS AND METHODS: PES1 expression was represented by boxplots. The correlation between PES1 expression and clinical features was assessed by the chi-squared test and Fisher's exact tests. Kaplan-Meier curves compared overall survival between different levels of PES1 expression, and Cox analysis selected potential variables associated with overall survival. The MTT assay investigated the proliferation rate, the scratch assay assessed the migratory ability, and the Transwell assay evaluated the invasion capacity of tumor cells in vitro. Animal models were used to confirm the tumorigenic roles of PES1 in vivo. GSEA illustrated the molecular mechanisms that PES1 participated in. RESULTS: We found that PES1 was highly expressed in liver cancer tissues, served as a diagnostic marker, and correlated with poor overall survival (OS) and relapse-free survival (RFS) in patients. In vitro studies indicated that PES1 promoted tumor cell proliferation (P=0.0034), migration (P=0.0026), and invasion (P=0.0008), and this tumorigenic role was confirmed in animal models. GSEA further illuminated molecular mechanisms that PES1 participated in liver cancer occurrence and progression. CONCLUSION: This study suggested that PES1 was upregulated in liver cancer and correlated with poor prognosis, by promoting tumor cell proliferation, migration, and invasion, and PES1 may be a novel diagnostic and prognostic bio-marker and a promising therapeutic target in liver cancer.