Volume 33,Issue 9,2024 Table of Contents

1 Innovation and development of robotic hepatobiliary and pancreatic surgery

WANG Guanyu , ZHANG Xiuping , LIU Rong

2024, 33(9):1357-1367. DOI: 10.7659/j.issn.1005-6947.2024.09.001

[Abstract](147) [HTML](69) [PDF 1.41 M](619)

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In the 21st century, surgery has entered the 4.0 era, also known as the era of surgical intelligence. As technology continues to improve and advance, robotic surgery has become an important direction of development in the field of minimally invasive surgery. With significant technical advantages such as high-definition 3D stereoscopic vision and the elimination of physiological tremors, robotic surgery is increasingly being applied in the field of hepatobiliary and pancreatic surgery, gradually becoming the primary surgical approach in this domain. Compared to traditional open surgery and laparoscopic surgical techniques, robotic hepatobiliary and pancreatic surgery demonstrates notable advantages in terms of precision and safety. It not only reduces intraoperative blood loss but also shortens postoperative hospitalization, thereby accelerating patient recovery. The authors' center is one of the largest robotic hepatobiliary and pancreatic surgery centers in the world. Since 2011, it has pioneered robotic hepatobiliary and pancreatic surgery and successfully performed nearly 10 000 cases, gaining a wealth of surgical experience. During this period, the authors' team established a complete robotic hepatobiliary and pancreatic surgery system. This article summarizes the latest research developments in the field of robotic hepatobiliary and pancreatic surgery at home and abroad, combining the rich clinical experience of the authors' center, to provide an in-depth review of the progress and and emerging surgical techniques in robotic pancreatic surgery, liver surgery, and biliary surgery, and also offer an outlook on future trends in robotic hepatobiliary and pancreatic surgery.

2 Application of intraoperative ultrasound in robot-assisted precise resection of pancreatic tumors

LI Zheng , LIU Wensheng , ZHUO Qifeng , SHI Yihua , JI Shunrong , YU Xianjun , XU Xiaowu

2024, 33(9):1368-1376. DOI: 10.7659/j.issn.1005-6947.2024.09.002

[Abstract](72) [HTML](57) [PDF 1.19 M](444)

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The incidence and detection rates of benign and low-grade malignant pancreatic tumors have risen yearly. For patients with such tumors, traditional radical resection procedures often result in excessive loss of normal pancreatic parenchyma, leading to complications such as postoperative insufficiency of both exocrine and endocrine functions. Studies have shown that functional-preserving surgeries, such as minimally invasive enucleation or partial resection surgeries, can maximize the protection of patients' pancreatic function and improve long-term quality of life. However, for some tumors deep within the pancreatic parenchyma, accurately locating the tumor and protecting the pancreatic duct pose challenges. Intraoperative ultrasound (IOUS) has become an ideal intraoperative imaging tool, often referred to as the surgeon's "third eye" because of its portability, ability to provide real-time high-resolution information, non-reliance on ionizing radiation, and the fact that it does not require special patient preparation. With advancements in technology, the application scope of IOUS has expanded beyond its initially limited diagnostic role to various surgical applications, including identifying non-palpable lesions, guiding surgical strategies, and staging tumors. In the current era of minimally invasive and precision surgery, the proficiency of surgeons in using IOUS has become an important issue. This article reviews the history of IOUS applications, summarizes the advantages and basic usage methods of robotic IOUS, and shares techniques for applying IOUS in robot-assisted precise resection of pancreatic tumors.

3 Surgical intervention in the treatment of severe acute pancreatitis

LI Guanqun , SUN Bei

2024, 33(9):1377-1384. DOI: 10.7659/j.issn.1005-6947.2024.09.003

[Abstract](133) [HTML](56) [PDF 760.64 K](523)

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Severe acute pancreatitis (SAP) has a mortality rate of up to 30%, and its incidence continues to rise each year, posing a significant economic and social burden. Nearly half of SAP patients may develop local complications such as infected pancreatic necrosis in the later stages of the disease, with treatment focused on controlling infection and its associated complications. With the development of minimally invasive treatment techniques, the "step-up" treatment strategy centered on minimally invasive techniques has improved patient outcomes. Surgical intervention plays a critical role in this treatment process, primarily by accurately determining the indications, timing, and methods for surgical intervention. This article discusses surgical intervention strategies for SAP, aiming to optimize the holistic treatment of SAP patients further.

4 Surgical management and treatment of infected pancreatic necrosis

LI Fei , HUANG Bohan

2024, 33(9):1385-1391. DOI: 10.7659/j.issn.1005-6947.2024.09.004

[Abstract](61) [HTML](43) [PDF 987.29 K](350)

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Acute pancreatitis is one of the common acute abdominal conditions in the digestive system, and its incidence is on the rise. Although approximately 80% of cases involve mild patients without local complications, some patients develop local complications in the later stages of the disease, such as pancreatic pseudocysts and walled-off necrosis. Among these, infected pancreatic necrosis (IPN) is the most severe, with a mortality rate of up to 30%. In recent years, treatment approaches centered around minimally invasive surgery have achieved promising results; several recent clinical trials have also provided substantial new insights into the surgical diagnosis and treatment of IPN. However, it is worth noting that IPN exhibits considerable individual variability and complex treatment processes. Therefore, it is necessary to discuss surgical treatment strategies for IPN to offer clinical practitioners a reference for relevant management.

5 Diagnosis and treatment of infected pancreatic necrosis with abdominal hemorrhage

GAO Kun , TONG Zhihui , LI Weiqin

2024, 33(9):1392-1397. DOI: 10.7659/j.issn.1005-6947.2024.09.005

[Abstract](48) [HTML](38) [PDF 770.86 K](377)

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Abdominal hemorrhage is one of the most severe complications of infected pancreatic necrosis (IPN). Common causes of bleeding include arterial, venous, coagulopathy-related, and iatrogenic factors. The preferred treatment for IPN complicated by abdominal bleeding is digital subtraction angiography (DSA) combined with transcatheter arterial embolization. For patients with repeated negative DSA results, ineffective conservative treatment, or acute bleeding with extremely unstable vital signs, emergency surgery is required. The surgery should follow the principles of damage control. Preventing bleeding in IPN patients is a top priority for future work. This article, based on the diagnostic and treatment experience of the authors' team as well as relevant research findings, shares thoughts and discusses with fellow professionals regarding the diagnosis and treatment of IPN with abdominal hemorrhage.

6 Advances in early precision diagnosis and treatment of severe acute pancreatitis

SUN Zefang , HUANG Gengwen

2024, 33(9):1398-1405. DOI: 10.7659/j.issn.1005-6947.2024.09.006

[Abstract](71) [HTML](88) [PDF 727.20 K](704)

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Severe acute pancreatitis (SAP) is a rapid onset and complex acute digestive system emergency, often accompanied by severe local and systemic complications, leading to a high mortality rate. In recent years, with the continuous update of treatment concepts, especially the advancement of endoscopic and minimally invasive surgical techniques, the prognosis of SAP patients has significantly improved. However, in clinical practice, particularly in the early stages of the disease, there are still widespread issues of non-standard and imprecise diagnostic and therapeutic practices, which are important factors contributing to the occurrence of severe complications in the later stages of the disease and a major reason for the poor prognosis of SAP patients. In light of this, this article systematically reviews high-quality literature from recent years and combines the latest clinical research findings from the authors' team to summarize advancements in early precise diagnosis and treatment of SAP, providing new evidence for standardized treatment of SAP, which will undoubtedly help further improve the overall treatment outcomes for SAP.

7 Advancements and deliberation on the International Consensus Guidelines on Robotic Pancreatic Surgery (2023 Edition)

CAO Yu , ZHANG Xiuping , LIU Rong

2024, 33(9):1406-1413. DOI: 10.7659/j.issn.1005-6947.2024.09.007

[Abstract](70) [HTML](27) [PDF 930.16 K](538)

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With advancements in robotic surgery technology and applications, its prospects in pancreatic surgery are becoming increasingly promising. Recent studies have shown that robotic pancreatic surgery has unique advantages over open and laparoscopic methods in certain aspects. While the international minimally invasive surgery field continues to evolve, the comprehensive clinical application of robotic pancreatic surgery still requires evidence-based medical guidance. Our team has taken the lead in updating and publishing the International Consensus Guidelines for Robotic Pancreatic Surgery (2023 Edition) in the journal Hepatobiliary Surgery and Nutrition, based on the International consensus statement on robotic pancreatic surgery This effort brought together numerous experts in minimally invasive surgery from the United States, Europe, and Oceania. The analysis of 176 studies included after systematic literature evaluation was conducted using the World Health Organization (WHO) Handbook for Guideline Development, GRADE Grid method, Delphi vote, and AGREE-Ⅱ instrument. Detailed discussions were provided on topics such as robotic pancreatoduodenectomy, robotic distal pancreatectomy, and robotic central pancreatectomy. Following expert assessments and a comprehensive evaluation of evidence quality and credibility, 19 questions and 14 recommendations were proposed, aiming to provide a basis for the safe and effective promotion of robotic pancreatic surgery in comprehensive or specialty medical centers both in China and elsewhere. The new consensus also emphasizes the importance of randomized controlled trial evidence for several issues, highlighting a direction for further efforts to promote the safe and effective implementation of robotic pancreatic surgery.

8 Interpretation of the updates in the 2024 American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

JI Liandong , YUAN Hongtao , WEI Wei , DOU Xiaolin , CHEN Guo , GONG Xuejun

2024, 33(9):1414-1421. DOI: 10.7659/j.issn.1005-6947.2024.09.008

[Abstract](99) [HTML](95) [PDF 736.24 K](1075)

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The American College of Gastroenterology Guidelines: Management of Acute Pancreatitis (referred to as the "2024 guidelines"), released in March 2024, presents 11 recommendations and 23 key concepts for the management of acute pancreatitis (AP) based on different levels of evidence quality. The 2024 guidelines provide detailed explanations regarding the diagnostic criteria, etiology, initial assessment, severity stratification, initial management, endoscopic retrograde cholangiopancreatography, antibiotic use, nutritional support, and surgical interventions for AP. Compared to the 2023 edition of the American College of Gastroenterology Guidelines, the 2024 edition offers more detailed recommendations and comprehensive evidence-based medical data, which is of great significance in optimizing the diagnosis and treatment process for AP patients and improving patient outcomes.

9 Application of mechanical principles in pancreaticoduodenectomy: "1-tube, 2-needle, 3-suture" pancreaticojejunostomy (with video)

ZHANG Jinming , SHA Hongcun , CHEN Mingyu

2024, 33(9):1422-1429. DOI: 10.7659/j.issn.1005-6947.2024.09.009

[Abstract](57) [HTML](136) [PDF 1.50 M](742)

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The pancreatojejunostomy is one of the most challenging steps in pancreatic reconstruction surgery, and its success directly impacts the patient's prognosis. The pancreas has characteristics such as being narrow at the top and wide at the bottom, fragile in texture, rich in digestive enzymes, and subject to constant intestinal peristalsis. These factors can easily lead to the loosening of the pancreatojejunostomy site and the occurrence of postoperative pancreatic fistula. Through mechanical modeling analysis and a summary of clinical practice, the authors propose a pancreatojejunostomy method based on mechanical principles. This method is summarized as "1-tube, 2-needle, 3-suture" method, which refers to one pancreatic duct stent tube, two types and two strands of different sutures, and three different suturing techniques. This article will provide a detailed introduction to this operative method and deeply analyze its technical principles. Additionally, a retrospective analysis of cases from the authors' center found that this method can effectively reduce the incidence of postoperative pancreatic fistula.

10 Comparison of efficacy and safety between robotic and laparoscopic pancreatic tumor enucleation

LI Zhiqiang , SUN Jichun , TU Guangping , XIE Shuangxi , LIU Yunfei , WANG Dongwen , HE Shunmin , YU Xiao

2024, 33(9):1430-1439. DOI: 10.7659/j.issn.1005-6947.2024.09.010

[Abstract](47) [HTML](28) [PDF 801.57 K](320)

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Background and Aims In the era of minimally invasive surgery, the role of pancreatic tumor enucleation (PTE) in treating benign or low-grade malignant tumors is gaining attention. The Da Vinci robot offers advantages such as enhanced visualization and flexible instrument manipulation, which can ensure the safe implementation of PTE. However, whether robotic pancreatic tumor excision (RPTE) is superior to laparoscopic pancreatic tumor enucleation (LPTE) remains undetermined. Therefore, this study was performed to explore this aspect.Methods The clinical data of 38 patients who underwent surgical treatment for benign or low-grade malignant tumors in the Third Xiangya Hospital of Central South University from April 2020 to May 2024 were collected. Among them, 18 cases underwent RPTE (RPTE group), and 20 cases underwent LPTE (LPTE group). Relevant clinical variables were compared between the two groups, and subgroup comparisons were further conducted for patients with tumors in the head and neck/body/tail of the pancreas.Results The average operative time for the entire group was 125 min, with an average intraoperative blood loss of 67.89 mL, and no C-grade pancreatic fistula occurred. The incidence rates of B-grade pancreatic fistula, postoperative bleeding, and readmission were 39.5%, 21.1%, and 18.4%, respectively, with an average postoperative hospital stay of 11.44 d. Overall, the RPTE group had shorter operative time and less intraoperative blood loss than the LPTE group (both P<0.05). There were no statistically significant differences between the two groups regarding the incidence of B-grade pancreatic fistula, intraoperative bleeding, readmission rate, and postoperative hospital stay (all P>0.05). Subgroup analysis showed that for patients with head tumors, the RPTE group had shorter operative time, less intraoperative blood loss, and a lower incidence of postoperative bleeding than the LPTE group (all P<0.05). However, the differences in the incidence of B-grade pancreatic fistula, readmission rate, and postoperative hospital stay were not statistically significant (all P>0.05). In patients with neck/body/tail tumors, the RPTE group also had shorter operative time and less intraoperative blood loss (both P<0.05), but the differences in incidence of B-grade pancreatic fistula, incidence of postoperative bleeding, readmission rate, and postoperative hospital stay were not statistically significant (all P>0.05).Conclusion Minimally invasive PTE for the treatment of benign or low-grade malignant pancreatic tumors is safe. Compared to LPTE, RPTE can significantly reduce operative time and intraoperative blood loss and shows certain advantages in reducing postoperative complications, particularly for patients with head tumors. However, the conclusion of this study needs to be confirmed by larger prospective studies.

11 Meta-analysis comparing the efficacy of pancreaticoduodenectomy with Heidelberg triangle operation and standard pancreaticoduodenectomy in the treatment of pancreatic cancer

SHU Qiang , XU Bo , WANG Qinghai , ZHONG Sheng , LIU Xiaoling , XIANG Xin

2024, 33(9):1440-1450. DOI: 10.7659/j.issn.1005-6947.2024.09.011

[Abstract](65) [HTML](49) [PDF 927.48 K](441)

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Background and Aims There is currently no consensus on whether the pancreaticoduodenectomy with Heidelberg triangle operation (PD_TRIANGLE) or the standard radical pancreaticoduodenectomy (PD_STANDARD) is more beneficial for patients with pancreatic cancer, and no large-scale multicenter studies have confirmed this. Therefore, this study was conducted to compare the clinical efficacy and safety of PD_TRIANGLE and PD_STANDARD for treating pancreatic cancer through a Meta-analysis.Methods Relevant literature comparing the two surgical approaches comparing the two surgical approaches for treating pancreatic cancer was screened from Chinese and English databases based on inclusion criteria. The search timeframe extended from the inception of the databases to May 2024, and Review Manager 5.3 software was used for Meta-analysis of the extracted outcome variables.Results A total of 6 retrospective studies were included, comprising 658 patients, with 315 in the PD_TRIANGLE group and 343 in the PD_STANDARD group. The Meta-analysis results showed that the operative time in the PD_TRIANGLE group was longer than that in the PD_STANDARD group (OR=1.52, 95% CI=0.42-2.61, P=0.007), the lymph node dissection rate was higher in the PD_TRIANGLEgroup (OR=0.70, 95% CI=0.4-1.01, P<0.000 01), and the R₀ resection rate was also higher in the PD_TRIANGLE group (OR=1.63, 95% CI=1.03-2.58, P=0.04). The incidence rates of postoperative lymphatic fistula and diarrhea were higher in the PD_TRIANGLE group compared to the PD_STANDARD group (OR=5.60, 95% CI=1.81-17.29, P=0.003; OR=0.13, 95% CI=0.07-0.20, P<0.000 1). The length of hospital stay was longer in the PD_TRIANGLE group (OR=0.40; 95% CI=0.14-0.65, P=0.003). The overall survival rates at 1 and 2 years were significantly better in the PD_TRIANGLE group compared to the PD_STANDARD group (OR=2.19, 95% CI=1.27-3.76, P=0.005; OR=1.65, 95% CI=1.01-2.67, P=0.04), and the 1-year disease-free survival rate was also significantly higher in the PD_TRIANGLE group (OR=3.71, 95% CI=2.27-6.07, P<0.000 01), although the difference in the 2-year disease-free survival rate between the two groups was not statistically significant (OR=2.63, 95% CI=0.91-7.59, P=0.07).Conclusion PD_TRIANGLE is a safe and effective treatment for pancreatic cancer. Compared to PD_STANDARD, PD_TRIANGLE significantly improves the R₀ resection rate, thereby enhancing the postoperative disease-free survival rate and achieving a better long-term prognosis.

12 Application of the curettage and suction dissection method with PMOD in pancreaticoduodenectomy

GUO Yan , NIU Heyuan , LI Jun , MENG Xingkai

2024, 33(9):1451-1458. DOI: 10.7659/j.issn.1005-6947.2024.09.012

[Abstract](53) [HTML](28) [PDF 753.28 K](335)

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Background and Aims Severe and multiple complications significantly affect the survival of patients after pancreaticoduodenectomy (PD). Previous studies have primarily focused on improving anastomosis techniques to reduce postoperative fistulas, with limited research on anatomical approaches to decrease complications and improve patient outcomes. This article summarizes our team's experience in applying curettage and suction dissection method in PD and analyzes its safety and clinical efficacy.Methods The clinical data from patients undergoing elective PD in the Department of Hepatobiliary Surgery of Inner Mongolia Medical University Hospital from January 2021 to June 2023 were retrospectively collected. Patients using the curettage and suction dissection method were designated as the observation group, while those using traditional anatomical techniques were served as the control group. The observation group utilized the Peng's multifunctional operational dissector (PMOD), whereas the control group used conventional electrotome and ultrasonic scalpel during operation. The main clinical variables between the two groups were compared, and factors affecting postoperative survival of patients were also analyzed.Results A total of 169 patients were included, with 59 in the observation group and 110 in the control group. No significant differences in baseline characteristics were found between the groups (all P>0.05). The observation group exhibited more nerve infiltration during surgery than the control group (64.41% vs. 39.09%, P=0.002), but had significantly shorter operative time (236 min vs. 330 min, P<0.01). There were no significant differences in lymph node metastasis, blood loss, or vascular infiltration between the two groups (all P>0.05). The incidence of postoperative pancreatic fistula was significantly lower in the observation group than that in the control group (16.9% vs. 40.0%, P=0.002). No significant differences were noted between the groups in terms of reoperation rate within one month, postoperative hospitalization duration, bile leakage, bleeding, infection, delayed gastric emptying or survival (all P>0.05). Multivariate Logistic regression analysis identified smoking, tumor nerve infiltration, and delayed gastric emptying as independent risk factors affecting survival (all P<0.05).Conclusion Using curettage and suction dissection method with PMOD in PD is safe and feasible. It is simpler, less invasive, and results in shorter operative time compared to traditional method, indirectly reducing postoperative complications. Its clinical efficacy is reliable, suggesting potential for broader application in clinical practice.

13 Construction and validation of a prognostic model for pancreatic ductal adenocarcinoma based on machine learning algorithm

ZHANG Yeguang , ZHAO Pan , ZHANG Hui , HUANG Zhenghong , HUANG Kun

2024, 33(9):1459-1472. DOI: 10.7659/j.issn.1005-6947.2024.09.013

[Abstract](57) [HTML](31) [PDF 2.06 M](457)

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Background and Aims Pancreatic ductal adenocarcinoma (PDAC) is the most common pathological type of pancreatic cancer, with a poor long-term prognosis and a lack of individualized prognostic assessment tools. This study was conducted to construct a prognostic nomogram for PDAC patients based on large-sample real-world data from the SEER database using machine learning algorithms to provide precise and individualized prognostic evaluations to inform clinical decision-making.Methods The clinical and prognostic data of PDAC patients pathologically diagnosed from 2000 to 2018 were extracted from the SEER database based on inclusion and exclusion criteria. The data were randomly divided into training (70%) and validation (30%) sets. In the training set, independent prognostic factors were identified using univariate and multivariate Cox proportional hazards models, LASSO regression, and random survival forests. A nomogram was developed to predict 6, 12, and 36-month cancer-specific survival (CSS) and overall survival (OS). The model was then validated and assessed in both training and validation sets using the concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, survival curves, and decision curve analysis.Results A total of 4 237 patients were included, with 2 965 in the training set and 1 272 in the validation set, showing comparable baseline characteristics. The median follow-up time was 18 (9-36) months for the training set and 18 (9-37) months for the validation set. The multivariate Cox model indicated that age, T stage, N stage, M stage, differentiation, surgery, systemic therapy, and chemotherapy were independent factors for OS (all P<0.05). For CSS, age, T stage, N stage, M stage, differentiation, surgery, and chemotherapy were independent factors (all P<0.05). The LASSO regression model found that age, differentiation, T stage, N stage, M stage, chemotherapy, surgery, lymph node dissection, radiotherapy, and systemic therapy were associated with OS, while T stage, N stage, M stage, chemotherapy, surgery, lymph node dissection, radiotherapy, and systemic therapy were linked to CSS. The random survival forest model identified the top five variables affecting OS as systemic therapy, differentiation, N stage, chemotherapy, and T stage; and for CSS, they were systemic therapy, differentiation, N stage, chemotherapy, and AJCC stage. Based on the analyses from the multivariate Cox, LASSO, and random survival forest model, along with clinical significance, a prediction model was successfully constructed using seven clinical features: age, T stage, N stage, M stage, differentiation, surgery, and chemotherapy to predict OS and CSS at 6, 12, and 36 months. The validation results showed C-indexes of 0.692 (95% CI=0.681-0.704) and 0.680 (95% CI=0.664-0.698) for OS in the training and validation sets, respectively, and 0.696 (95% CI=0.684-0.707) and 0.680 (95% CI=0.662-0.698) for CSS. ROC curves indicated good predictive value, and calibration curves closely matched the ideal 45° reference line.Conclusion Age, TNM stage, differentiation, surgery, and chemotherapy are independent prognostic factors for PDAC patients. The prognostic model based on these variables has high discrimination and accuracy, assisting clinicians in developing precise and personalized treatment and follow-up plans for PDAC patients.

14 Analysis of the efficacy of enteral nutrition combined with step-up drainage in the treatment of acute necrotizing pancreatitis complicated by duodenal fistula

ZHANG Jingzhu , LI Gang , ZHOU Jing , YE Bo , KE Lu , TONG Zhihui , LI Weiqin

2024, 33(9):1473-1480. DOI: 10.7659/j.issn.1005-6947.2024.09.014

[Abstract](58) [HTML](23) [PDF 959.24 K](447)

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Background and Aims The occurrence of duodenal fistula following infected pancreatic necrosis (IPN) in the later stage of treatment for acute necrotizing pancreatitis presents a significant clinical challenge. It often leads to severe complications such as difficulty in administering enteral nutrition, electrolyte imbalances, abdominal bleeding, and worsening infections. This study was performed to explore the efficacy of enteral nutrition combined with step-up drainage in treating IPN complicated by duodenal fistula and to share single-center experience.Methods The clinical data of 66 patients with IPN complicated by duodenal fistula who underwent enteral nutrition combined with step-up drainage in the Severe Pancreatitis Treatment Center of the Nanjing Eastern Theater General Hospital between January 2018 and December 2020 were retrospectively analyzed.Results Among the 66 patients, the median time from disease onset to the development of duodenal fistula was 53 (32-75) d. In 46 cases (69.7%), suspicious digestive fluid-like discharge was observed from drainage tube or double-lumen tube. The diagnosis and location of the duodenal fistula were confirmed in 49 patients (74.2%) through fistulography, while the remaining cases were confirmed via surgical exploration or endoscopy. The duodenal fistulas were mainly located in the horizontal part (33.3%) or descending part (50.0%) of the duodenum. Nutritional access was safely established through nasojejunal tube in 61 patients (92.4%), while 5 patients (7.6%) required surgery to establish the access. Twenty patients (30.3%) experienced secondary abdominal bleeding, and 14 patients (21.2%) died. Among the 52 patients who recovered, 49 (94.2%) healed through step-up drainage, while 3 (5.8%) required surgery due to delayed healing. Of the 49 patients who underwent non-surgical treatment, 10 (20.4%) achieved fistula closure through drainage tube, and 39 (79.6%) achieved closure through continuous lavage drainage via double-lumen tube. The median healing time for duodenal fistula in non-surgically treated patients was 41 (29-80) d.Conclusion Patients with IPN complicated by duodenal fistula are in a critical condition. Enteral nutrition combined with step-up drainage is an effective treatment for these patients.

15 The clinical application value of next-generation sequencing technology based on metagenomics capture for identifying pathogens in infected pancreatic necrosis

LIU Baiqi , LI Jiarong , HONG Xiaoyue , LIN Jiayan , NING Caihong , SUN Zefang , ZHU Shuai , CHEN Lu , SHEN Dingcheng , YU Yan , HUANG Gengwen

2024, 33(9):1481-1487. DOI: 10.7659/j.issn.1005-6947.2024.09.015

[Abstract](42) [HTML](23) [PDF 792.06 K](334)

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Background and Aims Accurate early pathogen diagnosis is a breakthrough for improving the prognosis of infectious pancreatic necrosis (IPN) patients. However, there is currently a lack of efficient methods for early identification of IPN in clinical settings. This study was performed to assess the application value of next-generation sequencing technology based on metagenomic capture (MetaCAP) in the pathogen diagnosis of IPN.Methods A prospective study was conducted on 29 patients suspected of having acute necrotizing pancreatitis at Xiangya Hospital of Central South University between January and July 2024. Blood samples were tested using MetaCAP and conventional pathogen culture. The results of peritoneal fluid pathogen culture were used as the gold standard to compare the diagnostic efficacy of the two methods.Results Due to three cases lacking peritoneal fluid culture results, a total of 26 cases were included in the final analysis. The overall mortality rate was 23.1% (6/26). During hospitalization, 9 cases (34.6%) were diagnosed with IPN. The sensitivity and negative predictive value of MetaCAP for diagnosing IPN were significantly higher than those of conventional pathogen culture (77.8% vs. 11.1%, P=0.031; 86.7% vs. 65.2%, P=0.032), while the differences in specificity (76.5% vs. 88.2%, P=0.689) and positive predictive value (63.6% vs. 33.3%, P=0.347) between the two methods were not statistically significant. The average detection time for MetaCAP was 33 (20-49) h, while microbial culture took 125 (45-142) h, with a significant difference (P<0.001). The average cost for blood MetaCAP testing was 2 500 yuan per case, but it accounted for only 1.19% of the average hospitalization cost.Conclusion MetaCAP has significant value in the early pathogen diagnosis of IPN, with a shorter detection time, good testing efficacy, and health-economic value, demonstrating a promising clinical application prospect.

16 Expression of methylenetetrahydrofolate dehydrogenase 1 in pancreatic cancer and its clinical significance

ZHANG Gongming , LIU Yi , HU Wei , DU Shengwang

2024, 33(9):1488-1498. DOI: 10.7659/j.issn.1005-6947.2024.09.016

[Abstract](64) [HTML](30) [PDF 1.88 M](393)

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Background and Aims Methylenetetrahydrofolate dehydrogenase 1 (MTHFD1) is essential in various tumors. However, the role of MTHFD1 in pancreatic cancer remains unclear. This study was conducted to explore the expression and clinical significance of MTHFD1 in pancreatic cancer through bioinformatics analysis and clinical sample validation, as well as to analyze its potential mechanisms of action in pancreatic cancer.Methods The GEPIA2 online platform was used to analyze the differential expression of MTHFD1, survival, and pathological stage in TCGA pancreatic cancer data, examining the relationship between MTHFD1 expression and clinicopathologic features of pancreatic cancer patients. Univariate and multivariate analyses were performed using the Cox proportional hazards model on TCGA data. GO, KEGG, and GSEA analyses were conducted to predict the possible mechanisms of MTHFD1 in pancreatic cancer. The expression of MTHFD1 in 80 cases of pancreatic cancer and adjacent tissues was detected using immunohistochemistry, qRT-PCR, and Western blot and its expression with clinicopathologic characteristics was analyzed.Results In the TCGA database, MTHFD1 expression in pancreatic cancer tissues was significantly higher than in normal tissues (P<0.05). High expression of MTHFD1 was significantly associated with poor prognosis in pancreatic cancer patients (P=0.007). TCGA data indicated a close correlation between MTHFD1 expression and tumor stage (P<0.05). MTHFD1 expression was identified as an independent prognostic factor for pancreatic cancer (HR=1.777, P=0.01). GO, KEGG, and GSEA analyses showed that MTHFD1 was related to the cell cycle, and correlation heatmaps indicated a strong association between the MTHFD1 gene and the cell cycle. In the TIMER database, MTHFD1 expression level was significantly correlated with various immune cells, including B cells, CD8⁺ T cells, CD4⁺ T cells, macrophages, neutrophils, and dendritic cells (all P<0.05). The GDSC database revealed that patients with low MTHFD1 expression were more sensitive to various therapeutic agents than those with high expression. In clinical pancreatic cancer specimens, the positive expression rate of MTHFD1 and its mRNA and protein levels were significantly higher in cancer tissues than in adjacent tissues (all P<0.05). MTHFD1 expression was associated with tumor differentiation, clinical stage, lymph node metastasis, and neural infiltration (all P<0.05). Patients with high MTHFD1 expression had significantly shorter overall survival than those with low expression (P<0.05).Conclusion MTHFD1 is highly expressed in pancreatic cancer tissues and is associated with poor prognosis. It may participate in the occurrence and development of pancreatic cancer through the cell cycle and is related to the infiltration of tumor immune cells.

17 Effect of Huai'erjunzhi on invasion and migration of human cholangiocarcinoma cells and its action mechanism

TAN Yixuan , WANG Yanliang , ZHANG Zhensheng , ZHANG Yuexin , WANG Chaojun

2024, 33(9):1499-1506. DOI: 10.7659/j.issn.1005-6947.2024.09.017

[Abstract](40) [HTML](26) [PDF 1.15 M](355)

Abstract:
Background and Aims Cholangiocarcinoma, a rare malignant tumor, is difficult to diagnose and often detected at an advanced stage, limiting treatment options to palliative care. Conventional chemotherapy drugs have poor efficacy against cholangiocarcinoma, making the search for new treatments critical. This study was conducted to investigate the effects of Huai'erjunzhi on the malignant biological behavior of human cholangiocarcinoma cells and its relationship with the TGF-β/Smad pathway, aiming to provide a theoretical basis for the use of Huai'erjunzhi in cholangiocarcinoma treatment.Methods Human normal liver cells (L-02) and human cholangiocarcinoma cells (HuCCT1) were incubated with different concentrations of Huai'erjunzhi for various durations. Cell proliferation was assessed, and the half-maximal inhibitory concentration (IC₅₀) was calculated. HuCCT1 cells were divided into a negative control group (no intervention), a positive control group (15 mg/L cisplatin), and different Huai'erjunzhi intervention groups (1/5 IC₅₀, 2/5 IC₅₀, and IC₅₀ based on preliminary experimental results). Scratch and Transwell assays were used to measure cell migration and invasion, while Western blot was employed to detect the expression of proteins related to the TGF-β/Smad pathway in HuCCT1 cells.Results Only high concentrations of Huai'erjunzhi (>312.5 mg/L) significantly inhibited the proliferation of L-02 cells. Huai'erjunzhi significantly inhibited the proliferation of HuCCT1 cells at concentrations above 5 mg/L in a concentration-dependent manner (all P<0.05), with IC₅₀ values of 138.52 mg/L at 24 h, 99.41 mg/L at 48 h, and 113.52 mg/L at 72 h. Compared with the negative control group, the positive control group and the three Huai'erjunzhi intervention groups (20, 40, and 100 mg/L) exhibited reduced migration distance, decreased invasive cell numbers, lower expression of TGF-β1, Smad2, Smad3, Smad4, N-cadherin, Snail, and Slug, and increased expression of E-cadherin (all P<0.05). Compared with the positive control group, these changes in the Huai'erjunzhi groups were less pronounced but showed a clear concentration-dependent relationship (all P<0.05).Conclusion Huai'erjunzhi can potentially inhibit the malignant biological behavior of HuCCT1 cells by inhibiting the TGF-β/Smad pathway.

18 Multi-point acupuncture treatment to promote postoperative gastrointestinal function recovery in colorectal cancer patients: a prospective randomized controlled study

LIN Changwei , CHEN Shunkai , HU Gui , LI Xiaorong , GUO Yihang

2024, 33(9):1507-1516. DOI: 10.7659/j.issn.1005-6947.2024.09.018

[Abstract](63) [HTML](39) [PDF 1.13 M](389)

Abstract:
Background and aims Promoting gastrointestinal function recovery is one of the key aspects of enhanced recovery after surgery (ERAS) for colorectal cancer (CRC). Many ancient Chinese medical texts suggest that acupuncture at four acupoints—Zusanli, Shangjuxu, Sanyinjiao, and Neiguan—helps promote gastrointestinal peristalsis. However, there is currently no systematic study on multi-point acupuncture to promote postoperative gastrointestinal function recovery in CRC patients. Therefore, this study was conducted to evaluate the clinical efficacy of multi-point acupuncture in promoting gastrointestinal function recovery in CRC patients through a prospective study to provide new options for implementing ERAS in CRC patients in clinical practice.Methods Using a prospective, randomized, controlled design, a total of 100 eligible patients who underwent laparoscopic CRC radical surgery at the Department of Gastrointestinal Surgery, Third Xiangya Hospital of Central South University, between January 2021 and February 2022, were randomly divided into an observation group and a control group, with 50 patients in each group. Both groups underwent the same ERAS protocols and radical surgery during the perioperative period. The observation group received acupuncture treatment from the day of surgery to the third postoperative day, once per day, while the control group did not receive acupuncture. Primary outcomes included the time to bowel sound recovery, time to first flatus, and time to first defecation. Secondary outcomes included abdominal pain scores, incidence of bloating, nausea, vomiting, white blood cell count, neutrophil percentage, C-reactive protein, hemoglobin, serum albumin, blood potassium levels, postoperative hospital stay, and incidence of postoperative complications.Results A total of 96 patients completed the study, with 48 in each group. There were no statistically significant differences in baseline characteristics such as age, gender, or surgery time between the two groups (all P>0.05). Compared with the control group, the observation group had a significantly shorter time for bowel sound recovery, first flatus, first defecation, and postoperative hospital stay (all P<0.05). Additionally, the observation group showed reduced abdominal pain scores on postoperative day (POD) 2 and 3, a lower incidence of bloating on POD 1 and 2, and a reduced incidence of nausea and vomiting on POD 3 (all P<0.05). There were no statistically significant differences in the remaining comparisons between the two groups (all P>0.05).Conclusion Multi-point acupuncture treatment can promote the recovery of gastrointestinal function in patients undergoing minimally invasive CRC surgery without increasing postoperative complications, and it is recommended for integration into routine ERAS protocols.

19 Transsinus nephroscopic debridement and catheter irrigation drainage for postoperative intra-abdominal infection: 4 cases report and literature review

WU Jiaxing , YAO Hongbing , JIANG Jianhui , ZHAO Dongkang , LU Caijin , KONG Juan , WANG Zewen

2024, 33(9):1517-1528. DOI: 10.7659/j.issn.1005-6947.2024.09.019

[Abstract](50) [HTML](33) [PDF 2.57 M](527)

Abstract:
Background and Aims Postoperative intra-abdominal infection (PIAI) is a common postoperative complication in abdominal surgery and a challenging issue worldwide, with a treatment failure rate of 68.3% and an in-hospital mortality rate as high as 40.8%. The key to managing this condition is early control of the infection source, debridement and adequate drainage. Delayed control of the infection source is an independent risk factor for predicting treatment failure. Many PIAI lesions are located deep within the abdominal cavity, lacking optimal routes for percutaneous drainage, and the risks and difficulties of reoperation are significant. Thus, controlling the infection source in PIAI is a difficult task. Here, the authors report the management of 4 PIAI patients treated with nephroscopic debridement and catheter irrigation and drainage via the sinus tract, aiming to provide clinical insights and references.Methods The clinical data of 4 patients undergoing nephroscopic debridement, catheter irrigation and drainage for PIAI from October 2020 to September 2022 in the Department of Hepatobiliary and Pancreatic Surgery of the Second Affiliated Hospital of Guilin Medical University were retrospectively analyzed. Key techniques of nephroscopic management of PIAI were summarized and contextualized with relevant literature.Results The 4 PIAI cases included a right-sided retroperitoneal abscess after catheter drainage for severe acute pancreatitis, a hepatic abscess at the liver raw surface after right hemihepatectomy, bile leakage and secondary duodenal fistula after laparoscopic choledocholithotomy and T-tube drainage, and a pancreatic abscess at the pancreatic raw surface after distal pancreatectomy with splenectomy. All patients underwent nephroscopic debridement and catheter irrigation and drainage via the sinus tract: guidewires were inserted into the drainage sinus tract, followed by a minimally invasive expansion drainage kit and nephroscopy; pus was irrigated out, and pus moss was clamped out with foreign body forceps under nephroscopy. Then, irrigation drainage tubes were placed under the guidance of the guidewire, and continuous irrigation and drainage were performed. The 4 patients underwent a total of 5 nephroscopic debridement and catheter irrigation and drainage procedures, with one case requiring two operations. The preoperative catheterization time ranged from 14 to 58 d, with an average of 38.4 d. One patient concurrently underwent choledochoscopy for stone extraction and biliary drainage via the T-tube sinus tract. The operative time ranged from 30 to 115 min, with an average of 67.4 min. Aside from one case of minor intraoperative bleeding, which stopped after injecting diluted norepinephrine solution into the sheath and blocking the sheath, there were no surgical complications in the other three cases. The postoperative drainage tube duration ranged from 7 to 30 d, with an average of 20.75 d. After treatment, all PIAI lesions disappeared, and no recurrence was observed during follow-up, which ranged from 16 to 40 months.Conclusion Nephroscopic debridement and catheter irrigation and drainage via the sinus tract for PIAI is simple, feasible, and safe, allowing for direct visualization to avoid organ damage. It is effective in removing pus and necrotic tissue, replacing drainage tubes, and can be repeatedly performed with high efficiency and remarkable results. This method is particularly suitable for patients with postoperative abdominal drainage tube obstruction combined with encapsulated intra-abdominal fluid collections.

20 A case report of multidisciplinary diagnosis and treatment of severe acute pancreatitis with severe abdominal infection and biliary stricture

WU Jiawen , KONG Rui , HU Jisheng , LUO Yan , SHI Jiachen , HAN Yuncheng , SUN Bei

2024, 33(9):1529-1535. DOI: 10.7659/j.issn.1005-6947.2024.09.020

[Abstract](47) [HTML](33) [PDF 1.27 M](326)

Abstract:
Severe acute pancreatitis (SAP) is a critical condition in general surgery settings, characterized by high mortality and poor prognosis. On February 28, 2024, the Department of Hepatobiliary Surgery at the First Affiliated Hospital of Harbin Medical University admitted a 36-year-old male patient. The patient presented with “upper abdominal pain accompanied by fever for three months and jaundice of the skin and sclera for one week.” Physical examination revealed 11 puncture tubes, and a palpable mass measuring 3 cm × 5 cm in the upper abdomen. Enhanced CT and magnetic resonance cholangiopancreatography indicated acute pancreatitis. The patient was diagnosed with “SAP, infectious pancreatic necrosis, and biliary stenosis.” He had severe abdominal infection and complex postoperative complications, making treatment challenging. Consequently, a multidisciplinary team (MDT) consultation was initiated. After three rounds of MDT consulfation and freating, the patient ultimately recovered successfully and was discharged. This article reviews the MDT treatment process for this patient and summarizes the characteristics of this condition based on relevant literature to provide insights and experience for clinical practice.

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Volume 33,Issue 9,2024 Table of Contents

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