Prediction of postoperative pancreatic fistula using a nomogram based on the updated definition

PURPOSE: The International Study Group on Pancreatic Fistula's definition of postoperative pancreatic fistula (POPF) has recently been updated. This study aimed to identify risk factors for POPF in patients having pancreaticoduodenectomy (PD) and to generate a nomogram to predict POPF.METHODS: Data on 298 patients who underwent PD from March 2012 to October 2017 was retrospectively reviewed and POPF statuses were redefined. A nomogram was constructed using data from 220 patients and validated using the remaining 78 patients. Independent risk factors for POPF were identified using univariate and multivariate analyses. A predictive nomogram was established based on the independent risk factors and was compared with existing models.RESULTS: Texture of the pancreas, size of the main pancreatic duct, portal vein invasion, and definitive pathology were the identified risk factors. The nomogram had a C-index of 0.793 and was internally validated. The nomogram performed better (C-index of 0.816) than the other most cited models (C-indexes of 0.728 and 0.735) in the validation cohort. In addition, the nomogram can assign patients into low- (less than 10%), intermediate- (10% to 30%), and high-risk (equal or higher than 30%) groups to facilitate personalized management.CONCLUSION: The nomogram accurately predicted POPF in patients having PD.

Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Postoperative pancreatic fistula remains one of the most common and troublesome complications following pancreaticoduodenectomy. No consensus exists regarding the optimal pancreaticojejunostomy reconstruction technique to reduce this complication. We aimed to perform a systematic review comparing two commonly used techniques of pancreaticojejunostomy reconstruction (duct-to-mucosa versus invagination), by meta-analysis and assessment of evidence quality.</p><p><b>METHODS</b>Databases searched including The Cochrane Library, Medline, PubMed, Embase, etc. Randomized controlled trials (RCTs) comparing duct-to-mucosa and invagination pancreaticojejunostomy were included. Outcomes of interest were pancreatic fistula rate, mortality, morbidity, reoperation and hospital stay. Pooled estimates were expressed as risk ratio (RR) or mean difference.</p><p><b>RESULTS</b>From 321 identified abstracts, four RCTs (467 patients; duct-to-mucosa: 232; invagination: 235) were included. Pancreatic fistula rate (RR, 0.74; 95% confidence interval (CI): 0.24-2.28; P = 0.60), mortality (RR, 1.18; 95% CI: 0.39- 3.54; P = 0.77), morbidity (RR, 0.91; 95% CI: 0.69-1.21; P = 0.53), reoperation (RR, 1.09; 95% CI: 0.54-2.22; P = 0.81) and hospital stay (mean difference, -1.78; 95% CI: -4.60-1.04; P = 0.22) were similar between techniques.</p><p><b>CONCLUSIONS</b>Duct-to-mucosa and invagination pancreaticojejunostomy are comparable with regards to assessed parameters. High-quality, large-volume, multi-center RCTs with standard outcome definitions are required.</p>

Distribution of sentinel lymph nodes in gastric cancer and factors correlated with its metastasis / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the distribution of sentinel lymph nodes in gastric cancer, and evaluate clinicopathologic characteristics leading its metastasis.</p><p><b>METHODS</b>The location of metastatic lymph nodes was analyzed retrospectively in 27 patients of gastric carcinoma with solitary lymph node metastases, and in 80 cases metastasis was limited to only 1 station in Japanese nodal classification. The clinicopathologic characteristics of the patients with solitary lymph node metastases and 111 cases without lymph node metastases were compared.</p><p><b>RESULTS</b>Twenty-five in 27 cases with solitary lymph node metastases were limited in level I. Skip metastasis occurred in 2 cases. Sentinel lymph nodes of 16 cases in 21 patients with the tumors in the lower and middle third stomach were located in less curvature (No. 3) and in greater curvature (No. 4). Sentinel lymph nodes of 3 cases in 6 patients in the upper third stomach were located in right cardia (No. 1). Multivariate analysis showed that the frequency of sentinel lymph node metastasis of pT(3) lesion was significantly higher than that of pT(1) lesion with an odds ratio of 4.926 (P < 0.01). The frequency of sentinel lymph node metastasis in the tumor located in the upper third stomach was significantly higher than that in lower third stomach, with an odds ratio of 4.381 (P < 0.05). Early gastric cancer had lower risk for sentinel lymph node metastasis than that in Borrmann type I cancer, with an odds ratio of 0.082 (P < 0.05).</p><p><b>CONCLUSIONS</b>Majority of sentinel lymph nodes are located in the regional perigastric lymph node groups close to the tumor. Skip metastasis is rare. Depth of invasion and location of tumor are correlated with sentinel lymph node metastasis. Sentinel lymph node assessment can instruct to determine extent of lymph node dissection for gastric cancer.</p>

Integrative therapy for postoperative intractable enterococcus faecium infections / 中华外科杂志

<p><b>OBJECTIVE</b>To assess the treatment of patients with infection of enterococcus faecium after surgery who failed to respond to antibiotics.</p><p><b>METHODS</b>Five patients after surgery were proved to have Enterococcus faecium infection by bacterial culture. They were treated by sensitive antibiotics but failed. Comprehensive treatment prescribed included immunoenhancements, enteral nutrition, and traditional Chinese medicines.</p><p><b>RESULTS</b>Four patients were discharged from the hospital after recovery, and was cared else where after 1 month treatment.</p><p><b>CONCLUSION</b>Comprehensive treatment is a better way to treat patients with refractory enterococcus faecium infection after surgery.</p>

Clinical significance and correlation between elevated serum TR6 and lympho-metastasis in gastric cancer / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the value of serum TR(6) for the diagnosis and TNM classification in patients with gastric carcinoma.</p><p><b>METHODS</b>Serum TR(6) levels were measured using ELISA method in 31 gastric cancer patients, 19 patients with nonmalignant conditions and 29 healthy individuals. TR(6) expression in tumor mass was studied with immunohistochemistry. TR(6) gene copy number in tumor tissues was evaluated by real time PCR.</p><p><b>RESULTS</b>Ninety-seven point nine percent (47 of 48 cases) of healthy individuals and patients with nonmalignant conditions were serum TR(6)-negative. In contrast, 71% (22 of 31 cases) of gastric cancer patients were serum TR(6)-positive. Serum TR(6) positiveness was closely correlated with tumor differentiation status and TNM classification. TR(6) gene amplification did not occur in gastric carcinoma.</p><p><b>CONCLUSIONS</b>Serum TR(6) levels were correlated significantly with TNM stage and histopathological type of tumor. This can help to determine the pre-operative TNM classification and to choose the optimal extent of lymph node dissection for gastric cancer.</p>