It remains uncertain how surgeons can safely pass the learning curve of laparoscopic pancreatoduodenectomy (LPD) without potentially harming patients. We aimed to develop a difficulty scoring system ...(DSS) to select an appropriate patient for surgeons.
A total of 773 elective pancreatoduodenectomy surgeries between July 2014 and December 2019, including 346 LPD and 427 open pancreatoduodenectomy cases, were included. A 10-level DSS for LPD was developed, and an additional 77 consecutive LPD surgeries which could provide information of the learning stage I of LPD externally validated its performance between December 2019 and December 2021.
The incidences of postoperative complications (Clavien-Dindo≥III) gradually decreased from the learning curve stage I-III (20.00, 10.94, 5.79%, P =0.008, respectively). The DSS consisted of the following independent risk factors: (1) tumor location, (2) vascular resection and reconstruction, (3) learning curve stage, (4) prognostic nutritional index, (5) tumor size, and (6) benign or malignant tumor. The weighted Cohen's κ statistic of concordance between the reviewer's and calculated difficulty score index was 0.873. The C -statistics of DSS for postoperative complication (Clavien-Dindo≥III) were 0.818 in the learning curve stage I. The patients with DSS<5 had lower postoperative complications (Clavien-Dindo≥III) than those with DSS≥5 (4.35-41.18%, P =0.004) in the training cohort and had a lower postoperative pancreatic fistula (19.23-57.14%, P =0.0352), delayed gastric emptying (19.23-71.43%, P =0.001), and bile leakage rate (0.00-21.43%, P =0.0368) in validation cohort in the learning curve stage I.
We developed and validated a difficulty score model for patient selection, which could facilitate the stepwise adoption of LPD for surgeons at different stages of the learning curve.
Backgrounds and objective
The technique of minimally invasive pancreatic surgeries has evolved rapidly, including minimally invasive pancreaticoduodenectomy (MIPD). However, controversy on safety and ...feasibility remains when comparing the MIPD with the open pancreaticoduodenectomy (OPD); therefore, we aimed to compare MIPD and OPD with a systemic review and meta-analysis.
Methods
Multiple electronic databases were systematically searched to identify studies (up to February 2016) comparing MIPD with OPD. Intra-operative outcomes, oncologic data, postoperative complications and postoperative recovery were evaluated.
Results
Twenty-two retrospective studies including 6120 patients (1018 MIPDs and 5102 OPDs) were included. MIPD was associated with a reduction in estimated blood loss (WMD −312.00 ml, 95 % CI −436.30 to −187.70 ml,
p
< 0.001), transfusion rate (OR 0.41, 95 % CI 0.30–0.55,
p
< 0.001), wound infection (OR 0.37, 95 % CI 0.20–0.66,
p
< 0.001) and length of hospital stay (WMD −3.57 days, 95 % CI −5.17 to −1.98 days,
p
< 0.001). Meanwhile, MIPD group has a higher R0 resection rate (OR 1.47, 95 % CI 1.18–1.82,
p
< 0.001) and more lymph nodes harvest (WMD 1.74, 95 % CI 1.03–2.45,
p
< 0.001). However, it had longer operation time (WMD 83.91 min, 95 % CI 36.60–131.21 min,
p
< 0.001). There were no significant differences between the two procedures in morbidities (
p
= 0.86), postoperative pancreatic fistula (
p
= 0.17), delayed gastric empting (
p
= 0.65), vascular resection (
p
= 0.68), reoperation (
p
= 0.33) and mortality (
p
= 0.90).
Conclusions
MIPD can be a reasonable alternative to OPD with potential advantages. However, further large-volume, well-designed RCTs with extensive follow-ups are suggested to confirm and update the findings of our analysis.
Adrenocorticotropic hormone-producing pancreatic neuroendocrine neoplasm (ACTHoma) is an exceedingly rare type of pancreatic neuroendocrine neoplasm (pNEN) that often causes ectopic ...adrenocorticotropic hormone syndrome. These neoplasms have been found to be very aggressive and challenging to treat. The current systematic review aimed to analyze the clinical features, immunohistochemical characteristics, diagnosis, therapy, and prognosis of ACTHoma.
A systematic review of the English- and Chinese-language literature was performed. PubMed, EMBASE, and Wanfang databases were searched to identify articles about ACTHoma in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.
A total of 210 studies encompassing 336 patients diagnosed with ACTHoma were selected for the systematic review, including 16 Chinese patients.
ACTHoma was more common in women (66.4%), and the mean age was 44.7 years. Tumors were generally large, and the mean tumor size was 4.43 cm. The incidence of clinical manifestations was: hypokalemia, 69.3%; diabetes, 63.2%; weakness, 60.1%, hypertension, 56.4%; moon face 41.1%; and edema, 37.4%. These tumors are more commonly found in the tail of pancreas, and the most frequent site of metastasis was the liver. The pNENs or other functioning pNENs could evolve into ACTHoma. ACTHoma is a very rare disease, and the mean follow-up time was 28.3 months.
In light of the challenges associated with pancreaticoduodenectomy (PD) and recent key improvements, this bibliometric analysis aimed to analyze the 100 top-cited (T100) articles related to PD ...surgery to widen the awareness of relevant research on this procedure.
The term “pancreaticoduodenectomy” was used to retrieve articles from the Web of Science Core Collection database. The 100 most cited manuscripts in the English language were identified and further analyzed by their countries of origin, publication journals, authors, and themes.
A thorough literature search was performed on the Web of Science until April 2020. The total number of citations for the T100 articles ranged from 227 to 3029. The T100 articles came from 18 different countries, with the USA accounting for the plurality (n = 72). Professor J.L. Cameron from Johns Hopkins Medicine USA published the most articles (n = 22), including one as the first author and two as a co-author. Furthermore, Johns Hopkins Medicine, USA, published the most articles on PD surgery (n = 24), with a total citation count of 14,151. The journal Annals of Surgery published 40 of the T100 articles, with 15,847 citations and an average citation count of 396. Among the T100 articles, the citation frequency following the year of publication showed a parabolic trend, with citations peaking in the 9th year following publication.
Our study identified and analyzed the T100 articles in PD surgery. The USA was the dominant country regarding articles, researchers, and institutions. The citations of the articles peaked in the 9th year after publication.
•This study was the first bibliometric analysis in the pancreaticoduodenectomy (PD) surgery field.•The burst detection showed laparoscopic pancreaticoduodenectomy has emerged in recent years.•The USA was the dominant country regarding articles, researchers, and institutions in PD surgery.
In contrast to normal tissue, cancer cells display profound alterations in protein synthesis and degradation. Therefore, proteins that regulate endoplasmic reticulum (ER) homeostasis are being ...increasingly recognized as potential therapeutic targets. The ubiquitin-proteasome system and autophagy are crucially important for proteostasis in cells. However, interactions between autophagy, the proteasome, and ER stress pathways in cancer remain largely undefined. This study demonstrated that withaferin-A (WA), the biologically active withanolide extracted from Withania somnifera, significantly increased autophagosomes, but blocked the degradation of autophagic cargo by inhibiting SNARE-mediated fusion of autophagosomes and lysosomes in human pancreatic cancer (PC) cells. WA specifically induced proteasome inhibition and promoted the accumulation of ubiquitinated proteins, which resulted in ER stress-mediated apoptosis. Meanwhile, the impaired autophagy at early stage induced by WA was likely activated in response to ER stress. Importantly, combining WA with a series of ER stress aggravators enhanced apoptosis synergistically. WA was well tolerated in mice, and displayed synergism with ER stress aggravators to inhibit tumor growth in PC xenografts. Taken together, these findings indicate that simultaneous suppression of 2 key intracellular protein degradation systems rendered PC cells vulnerable to ER stress, which may represent an avenue for new therapeutic combinations for this disease.
The risk factors for achieving textbook outcome (TO) after laparoscopic duodenum-preserving total pancreatic head resection (LDPPHR-t) are unknown, and no relevant articles have been reported so far. ...The aim of this study was to identify the risk factors for achieving TO after LDPPHR-t.
The risk factors for achieving TO after LDPPHR-t were retrospectively evaluated by logistic regression analysis in 31 consecutive patients from May 2020 to December 2021.
All LDPPHR-t procedures were successfully performed without conversion. There was no death within 90 days after surgery and no readmission within 30 days after discharge. The percentage of achieving TO after LDPPHR-t was 61.3% (19/31). Among the six TO items, the postoperative complication of grade B/C postoperative pancreatic fistula (POPF) occurred most frequently with 22.6%, followed by grade B/C bile leakage with 19.4%, Clavien-Dindo≥III complications with 19.4%, and grade B/C postpancreatectomy hemorrhage with 16.1%. POPF was the major obstacle to achieve TO after LDPPHR-t. Placing an endoscopic nasobiliary drainage (ENBD) catheter and prolonged operation time (>311 min) were significantly associated with the decreased probability of achieving TO after LDPPHR-t (odd ratio (OR), 25.775; P =0.012 and OR, 16.378; P =0.020, respectively). Placing an ENBD catheter was the only significant independent risk factor for POPF after LDPPHR-t (OR, 19.580; P =0.017). Bile leakage was the independent risk factor for postpancreatectomy hemorrhage after LDPPHR-t (OR, 15.754; P =0.040). The prolonged operation time was significantly correlated with Clavien-Dindo grade≥III complications after LDPPHR-t (OR, 19.126; P =0.024).
Placing the ENBD catheter was the independent risk factor for POPF and achieving TO after LDPPHR-t. In order to reduce POPF and increase the probability of achieving TO, placing an ENBD catheter should be avoided prior to LDPPHR-t.
Benchmarking, a novel measuring tool for outcome comparisons, is a recent concept in surgery. The objectives of this review are to examine the concept, definition, and evolution of benchmarking and ...its application in surgery.
The literature about benchmarking was reviewed through an ever-narrowing search strategy, commencing from the concept, definition, and evolution of benchmarking to the application of benchmarking and experiences of benchmarking in surgery. PubMed, Web of Science, Embase, and Science Direct databases were searched until 20 September 2022, in the English language according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.
In the first phase of the literature search, the development of benchmarking was identified. The definitions of benchmarking evolved from a surveying term to a novel quality-improvement tool to assess the best achievable results in surgery. In the second phase, a total of 23 studies were identified about benchmarking in surgery, including esophagectomy, hepatic surgery, pancreatic surgery, rectum resection, and bariatric surgery. All studies were multicenter analyses from national, international, or global expert centers. Most studies (87.0%) adopted the definition that benchmark was the 75th percentile of the median values of centers. Performance metrics to define benchmarks were clinically relevant intraoperative and postoperative outcome indicators.
Benchmarking in surgery is a novel quality-improvement tool to define and measure the best achievable results, establishing a meaningful reference to evaluate surgical performance.
Objective
The aim of this study was to compare the short- and long-term outcomes of laparoscopic surgery (LS) and open surgery (OP) for perihilar cholangiocarcinoma (PHC) using a large real-world ...dataset in China.
Methods
Data of patients with PHC who underwent LS and OP from January 2013 to October 2018, across 10 centers in China, were extracted from medical records. A comparative analysis was performed before and after propensity score matching (PSM) in the LS and OP groups and within the study subgroups. The Cox proportional hazards mixed-effects model was applied to estimate the risk factors for mortality, with center and year of operation as random effects.
Results
A total of 467 patients with PHC were included, of whom 161 underwent LS and 306 underwent OP. Postoperative morbidity, such as hemorrhage, biliary fistula, abdominal abscess, and hepatic insufficiency, was similar between the LS and OP groups. The median overall survival (OS) was longer in the LS group than in the OP group (NA vs. 22 months; hazard ratio HR 1.19, 95% confidence interval CI 1.02–1.39,
p
= 0.024). Among the matched datasets, OS was comparable between the LS and OP groups (NA vs. 35 months; HR 0.99, 95% CI 0.77–1.26,
p
= 0.915). The mixed-effect model identified that the surgical method was not associated with long-term outcomes and that LS and OP provided similar oncological outcomes.
Conclusions
Considering the comparable long-term prognosis and short-term outcomes of LS and OP, LS could be a technically feasible surgical method for PHC patients with all Bismuth–Corlett types of PHC.
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