International expert consensus on laparoscopic pancreaticoduodenectomy.

IMPORTANCE: While laparoscopic pancreaticoduodenectomy (LPD) is being adopted with increasing enthusiasm worldwide, it is still challenging for both technical and anatomical reasons. Currently, there is no consensus on the technical standards for LPD. OBJECTIVE: The aim of this consensus statement is to guide the continued safe progression and adoption of LPD. EVIDENCE REVIEW: An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreaticoduodenectomy. Statements were produced upon reviewing the literature and assessed by the members of the expert panel. The literature search and its critical appraisal were limited to articles published in English during the period from 1994 to 2019. The Web of Science, Medline, and Cochrane Library and Clinical Trials databases were searched, The search strategy included, but was not limited to, the terms 'laparoscopic', 'pancreaticoduodenectomy, 'pancreatoduodenectomy', 'Whipple's operation', and 'minimally invasive surgery'. Reference lists from the included articles were manually checked for any additional studies, which were included when appropriate. Delphi method was used to establish expert consensus and the AGREE II-GRS Instrument was applied to assess the methodological quality and externally validate the final statements. The statements were further discussed during a one-day face-to-face meeting at the 1st Summit on Minimally Invasive Pancreatico-Biliary Surgery in Wuhan, China. FINDINGS: Twenty-eight international experts from 8 countries constructed the expert panel. Sixteen statements were produced by the members of the expert panel. At least 80% of responders agreed with the majority (80%) of statements. Other than three randomized controlled trials published to date, most evidences were based on level 3 or 4 studies according to the AGREE II-GRS Instrument. CONCLUSIONS AND RELEVANCE: The Wuhan international expert consensus meeting on LPD has produced a set of clinical practice statements for the safe development and progression of LPD. LPD is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. More robust randomized controlled trial and registry study are essential to proceed with the assessment of LPD.

Clinical Characteristics, Treatment, and Prognosis of Diabetic Foot Disease in Macao and Beijing: A Retrospective Study.

INTRODUCTION: There has been no epidemiological study of diabetes mellitus (DM) in Macao. Also, multidisciplinary treatment is yet to be popularized and complications of DM cannot be managed promptly in this region. Therefore, this study was performed to compare the clinical characteristics, treatment, and prognosis of diabetic foot disease between patients in Macao and Beijing. METHODS: A total of 243 patients with diabetic foot disease were enrolled: 124 from a tertiary hospital in Beijing and 119 from a tertiary hospital in Macao. The clinical profiles were collected and analyzed. RESULTS: The surgical treatment rate in the Beijing group (96.0%) was significantly higher than that in the Macao group (21.0%) (P < 0.05). The overall mortality rate was 14.8%, and cardiac failure was the most common cause (72.2%). Monthly household income and smoking were independent factors affecting the age of onset. Age of diabetes onset was a risk factor for the occurrence of diabetic foot disease; age, duration of diabetic foot disease, and length of smoking history were independent factors affecting the severity of diabetic foot disease. Renal dysfunction and activated partial thromboplastin time were independent factors affecting the survival time of patients with diabetic foot disease. CONCLUSIONS: Smoking may be a risk factor for the occurrence and development of diabetic foot; it can significantly reduce the onset age and aggravate the severity of this disease. The onset age of diabetic foot was lower in high-income patients, and prevention should be encouraged in this population. Elderly age may be associated with a rapidly developing and severe diabetic foot. The clinical course was also associated with the severity of diabetic foot. Renal and coagulation function should be closely monitored during the treatment of diabetic foot.

Endoscopic thyroidectomy via areola approach: summary of 1,250 cases in a single institution.

BACKGROUND: The aim of this study was to evaluate the effect and cosmetic results of endoscopic thyroidectomy (ETE) via the areola approach for patients with thyroid diseases. METHODS: A total of 1,250 patients with thyroid diseases underwent ETE via the areola approach between April 2005 and January 2011. Of these, 898 were benign goiters, 260 were Graves' disease, 28 were secondary hyperthyroidism, and 64 were papillary carcinomas. RESULTS: The surgery was successfully completed in 1,249 cases, and 1 case was converted to open surgery. The mean operation time, estimated blood loss, and hospital stay after surgery for patients with a goiter, hyperthyroidism, and papillary carcinoma were 94.4 min, 15.2 ml, 5.0 days, 97.9 min, 16.1 ml, 5.5 days, and 134.3 min, 18.6 ml, 6.4 days, respectively. Complications included 4 cases of postoperative bleeding, 1 case of transection of the recurrent laryngeal nerve (RLN) on one side, 7 cases of temporary RLN injury, 34 cases of transient hypocalcemia, 5 cases of skin bruising on the chest wall, and 1 case of subcutaneous infection in the neck. At 4.6-year (2.5-8 years) follow-up of 1,185 (94.8 %) patients, 3 patients with Graves' disease had recurrence of hyperthyroidism, and 4 patients with nodular goiter had recurrence of small nodules. Four patients had discomfort on swallowing, 4 patients had an abnormal sensation of skin traction on the neck and the chest, and 1 patient with scar diathesis had mild scar hyperplasia. A total of 876 patients were satisfied, 4 equivocal, and 0 unsatisfied with the cosmetic results. CONCLUSION: ETE via the areola approach for patients with benign goiters, Graves' disease, secondary hyperthyroidism, and papillary carcinomas without metastasis to lateral cervical lymph nodes is an effective and safe procedure with excellent cosmetic results.

Revascularization for iliac-femoral artery pseudoaneurysm with greater saphenous vein.

OBJECTIVE: To investigate the role of revascularization procedures with autologous greater saphenous vein in surgical management of iliac-femoral artery pseudoaneurysm in parenteral drug abusers. METHODS: Twenty-one patients with iliac-femoral artery pseudoaneurysm caused by parenteral drug abuse from 2004 to 2007 were enrolled. Among them, 15 patients were male and 6 were female; their average age was 31.3 years. The size of pseudoaneurysms ranged from 3.0 cm to 7.5 cm. Common femoral artery and distal external iliac artery were often involved. We performed arterial reconstruction on these patients with autologous greater saphenous vein as a graft after excising iliac-femoral artery pseudoaneurysm through a single curved inguinal incision. All patients were followed up, and the complications were recorded. RESULTS: The surgical procedures were finished without intraoperative mortality or perioperative complications. All patients were free of claudication symptoms after the surgery except one case with preoperative popliteal artery stenosis. One case of infection and wound tissue fistula was found later. One case had inguinal incisional hematoma and another complained of numbness in thigh skin. CONCLUSIONS: The use of autologous greater saphenous venous grafts for arterial reconstruction after pseudoaneurysm excision in drug abusers is safe and effective. This technique offers more advantages than arterial ligation alone without revascularization. An optimal greater saphenous venous graft is a prerequisite for revascularization.

Thoraco-abdominal aorta revascularization through a retroperitoneal approach / 中国医学科学杂志(英文版)

<p><b>OBJECTIVE</b>To investigate the application of the retroperitoneal approach in aortic surgery.</p><p><b>METHODS</b>We collected and analyzed data of 7 patients in Macau who presented with aortic diseases from 2007 to 2008 and were treated with aorta repair through retroperitoneal approach. Demographic features as well as intraoperative and postoperative data were analyzed. One case of thoracoabdominal aneurysm and 4 cases of abdominal aneurysm received artificial graft, among which hybrid iliac artery reconstruction with Zenith stent covering the ostium of the left subclavian artery was performed in 2 cases of infrarenal abdominal aneurysm. Aortic-iliac artery bypass was performed in 2 cases of aortoiliac occlusion.</p><p><b>RESULTS</b>No operative or early postoperative death was observed. No perioperative intestinal adhesion or ureteral obstruction was found. One case reported delayed paraplegia and graft infection as postoperative complications. The complications were partially removed 3 months later after rehabilitation.</p><p><b>CONCLUSION</b>Retroperitoneal approach is a safe and feasible technique, which associated with a low incidence of postoperative pulmonary complications.</p>

Hybrid endovascular aorta repair with simultaneous supra-aortic branch or iliac branch revascularization.

OBJECTIVE: To describe a hybrid endovascular procedure for aorta repair with different kinds of bypass followed by concomitant placement of stent graft in the aorta. METHODS: From June 2007 to May 2008, 5 consecutive patients who presented with aortic aneurysm or dissection were treated with a new hybrid aorta repair technique. Complete surgical rerouting of supra-aortic vessels was simultaneously created by endovascular repair of aortic arch aneurysm with stent graft. Hybrid left carotid-subclavian bypass with stent graft deployment covering the ostium of the left subclavian artery was performed in a Debakey type III aortic dissection case. The supra-aortic branch was revascularized in 2 cases from ascending aorta to bilateral common carotid arteries using a 16-8 mm bifurcated graft, then total aortic arch and descending artery was occluded with stent-graft. The left carotid artery to the left subclavian artery bypass was created in 1 case, followed by stent-graft deployment. Two cases of infrarenal abdominal aortic aneurysm underwent left external iliac artery to left internal iliac artery bypass by a retroperineal route, then hybrid procedure was performed with bifurcated stent-graft. All stent grafts were deployed via a retrograde femoral artery approach in 5 patients. RESULTS: Technical success with complete aneurysmal exclusion was achieved in all patients. There was no incidence of endoleak. During a follow-up period of 2 to 10 months, documented perioperative neurologic events did not occur in all patients. One patient suffered from adult respiratory distress syndrome. After received tracheostomy, he recovered later. There was one death resulting from a postoperative myocardial infarction. CONCLUSION: Hybrid arch repair provides an alternative therapy to patients otherwise considered prohibitively high risk for traditional open arch and thoracoabdominal aorta repair.