Objective To explore the predictive value of radiomics for postoperative pancreatic fistula, infection, and long-term survival in patients with pancreatic ductal adenocarcinoma (PDAC). Methods 206 patients who received radical resection of pancreatic cancer in Zhongshan Hospital, Fudan University from January 2014 to December 2020 and were pathologically confirmed as PDAC after surgery were retrospectively selected, all of whom had complete surgical data and long-term follow-up data. Pyradiomics was used to analyze the enhanced CT images of all patients and extract radiomics features. LASSO dimensionality reduction combined with logistic regression analysis was used to construct a predictive model for pancreatic fistula and abdominal infection after PDAC surgery, and evaluating the model’s effectiveness using ROC curves. A long-term survival prediction model for PDAC patients was constructed using LASSO dimensionality reduction combined with Cox regression analysis, and patient risk scores were calculated. The patients were divided into high-risk and low-risk groups based on the median, and the survival curves were compared to evaluate the effectiveness of the model. The imaging omics features with the highest weight were divided into high expression group and low expression group according to the median, and the prognostic differences and clinical features were compared. Radiomics and clinical features were combined to analyze the influencing factors of long-term prognosis and construct a clinical imaging comprehensive model. Results A total of 1 595 radiomics features were extracted. A predictive model for pancreatic fistula and infection after PDAC surgery was constructed, with AUC values of 0.81 and 0.79, respectively. The PDAC long-term survival prediction model was successfully constructed, and the prognosis of the high-risk group was worse than that of the low-risk group (P<0.001). The weight of the radiomics feature “log-sigma-5-mm-3D_glszm_ZonePercentage” was 59.557. The CA19-9 level in the high expression group is higher than that in the low expression group (P=0.017), and there is a statistically significant difference in survival curves between the two groups (P=0.021). The comprehensive clinical imaging model suggested that age, AJCC stage, lymph infiltration, CA19-9 level and imaging characteristics were risk factors for long-term prognosis of PDAC patients (HR=1.028, 4.084, 2.566, 1.232 and 2.536). Conclusions The predictive model based on radiomics has good predictive performance for pancreatic fistula, infection, and long-term prognosis after PDAC surgery. Patients with high expression of the radiomics feature “log-sigma-5-mm-3D_glszm_ZonePercentage” face poorer prognosis.

In the past two decades, significant advances have been made in the treatment of pancreatic cancer.Numerous first-line treatments, such as gemcitabine combined with erlotinib, gemcitabine combined with albumin-bound paclitaxel, FOLFIRINOX, and NALIRIFOX, have emerged;surgery-centered treatment has gradually become the mains clinical strategy.However, behind these achievements, the new drugs developed with substantial funding have not extended the median survival time of patients with advanced pancreatic cancer to more than one year; the 5-year survival rate for postoperative patients remains below 30%. While harboring hope and being proactive, researchers must also soberly reflect and continually reassess our direction, in anticipation of bringing tangible clinical benefits to pancreatic cancer patients at an early date.

The incidence of pancreatic cystic neoplasms increased dramatically. The clinically optimal management guideline for pancreatic cysts has continued to improve in previous decades. Some issues in diagnosis and treatment require careful consideration and decision-making to achieve the best therapeutic effect and avoid overtreatment. This article analyzes the new progress in the differential diagnosis of pancreatic cystic tumors, surgical decision-making and scope of surgery, and long-term follow-up of patients who have not undergone surgery. In general, the current diagnosis and treatment decisions for pancreatic cystic tumors are more comprehensive and scientific as evidence becomes increasingly abundant, emphasizing the risks and benefits of precise diagnosis and treatment and balanced treatment.

In the past two decades, significant advances have been made in the treatment of pancreatic cancer.Numerous first-line treatments, such as gemcitabine combined with erlotinib, gemcitabine combined with albumin-bound paclitaxel, FOLFIRINOX, and NALIRIFOX, have emerged;surgery-centered treatment has gradually become the mains clinical strategy.However, behind these achievements, the new drugs developed with substantial funding have not extended the median survival time of patients with advanced pancreatic cancer to more than one year; the 5-year survival rate for postoperative patients remains below 30%. While harboring hope and being proactive, researchers must also soberly reflect and continually reassess our direction, in anticipation of bringing tangible clinical benefits to pancreatic cancer patients at an early date.

The incidence of pancreatic cystic neoplasms increased dramatically. The clinically optimal management guideline for pancreatic cysts has continued to improve in previous decades. Some issues in diagnosis and treatment require careful consideration and decision-making to achieve the best therapeutic effect and avoid overtreatment. This article analyzes the new progress in the differential diagnosis of pancreatic cystic tumors, surgical decision-making and scope of surgery, and long-term follow-up of patients who have not undergone surgery. In general, the current diagnosis and treatment decisions for pancreatic cystic tumors are more comprehensive and scientific as evidence becomes increasingly abundant, emphasizing the risks and benefits of precise diagnosis and treatment and balanced treatment.

Intraductal papillary mucinous neoplasm (IPMN) is the most common pancreatic cystic neoplasm with a tendency to malignancy,and the 5-year survival rate of patients with invasive IPMN is less than 40%. Therefore,early detection of malignant cases and surgical intervention will significantly improve patient outcomes. The clinical guidelines recommended risk factors for IPMN malignancy according to imaging characteristics,clinical manifestations and serum tumor markers,among which dilation of the main pancreatic duct≥10 mm,the presence of solid components or enhanced mural nodules,and obstructive jaundice were recognized as high-risk factors. However,clinical practice has shown that the risk factors recommended by the current guidelines are not highly accurate in predicting IPMN malignancy,and the main problem is that the guidelines are less specific and allow follow-up cases to undergo unnecessary surgical resection. In recent years,the development of new technologies and methods such as genomics,radiomics,and artificial intelligence has greatly promoted the research progress of IPMN. Endoscopic ultrasound-guided fine needle aspiration of cystic fluid combined with molecular detection such as DNA and RNA,as well as radiomics combined with machine learning modeling,have shown superiority in improving the prediction accuracy of malignant IPMN,and will become an important tool to assist the diagnosis and treatment of IPMN in the future.

Objective:To investigate the treatment and prognosis of patients of G3 non-functional pancreatic neuroendocrine tumors (pNETs) with proliferation index of Ki-67 <55%.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 15 G3 non-functional pNETs patients with proliferation index of Ki-67<55% who were admitted to Zhongshan Hospital of Fudan University from April 2014 to April 2020 were collected. There were 11 males and 4 females, aged (58±10)years. All patients underwent radical resection of the primary lesion. Obser-vation indicators: (1) treatment; (2) postoperative pathological characteristics; (3) follow-up. Measure-ment data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M( Q1, Q3) or M(range). Count data were described as absolute numbers. The Pearson correlation analysis was used to verify the correlation between variables. Kaplan-Meier method was used to draw survival curve and calculate survival rate. Log-Rank test was used for survival analysis. Results:(1) Treatment. All 15 G3 nonfunctional pNETs patients underwent radical resection of the primary lesion of pancreas, including 5 cases receiving pancreati-coduodenectomy, 10 cases receiving distal pancreatectomy with splenectomy. There were 5 patients with simultaneous liver oligometastasis who underwent combined segmental (lobectomy) hepatectomy. All 15 patients had negative tumor margin, and the operation time and volume of intraoperative blood loss of 15 patients was 120(90,210)minutes and 200(50,300)mL, respectively. None of patient had complications ≥Ⅲ grade of the Clavien-Dindo classification during the postoperative 30 days. Of the 15 patients, there were 5 cases receiving comprehensive treatment based on CAPTEM chemo-therapy (temozolomide combined with capecitabine), 2 cases receiving local interventional therapy, 2 cases receiving CAPTEM chemotherapy, 1 case receiving local interventional therapy combined with molecular targeted therapy, 1 case receiving local interventional therapy combined with long acting somatostatin therapy, 1 cases receiving long acting somatostatin therapy combined with molecular targeted therapy, and 3 cases without postoperative treatment. (2) Postoperative patholo-gical characteristics. The tumor diameter of 15 patients was 3.3(range, 0.5-6.0)cm. There were 2 cases with tumor diameter <2 cm, 13 cases with tumor diameter ≥2 cm. The number of lymph nodes dissected and number of lymph nodes metastatic was 6(4, 10) and 2(1,3) in 15 patients, respectively, including 12 cases with positive lymph node metastasis. Of the 15 patients, there were 5 cases with tumor invasion of adjacent organ, 5 cases with simultaneous liver metastasis, 8 cases with perineural invasion and 8 cases with vascular invasion. There were 3, 7, and 5 patients with stage Ⅱ, stage Ⅲ, and stage Ⅳ of pathological TNM staging, respectively. The proliferation index of Ki-67 and mitotic count was 32%±9% and (11±9)/10 high power field in the primary lesion of 15 patients, respectively, and there was no correlation between proliferation index of Ki-67 and mitotic count ( P>0.05). (3) Follow-up. All 15 patients were followed up after surgery for (55±24)months. The median survival time of 15 patients was 78(range, 43-113)months, with 1-, 3-, 5-year overall survival rate as 100%, 92%, 62%, respectively. During the follow up, 9 of the 15 patients underwent tumor recurrence, with the recurrence time as 20(14, 44)months. There were 8 patients died of tumor recurrence or metastasis. The median survival time was 86(range, 51-120)months in 5 patients receiving comprehensive treatment based on CAPTEM chemotherapy, versus 53(range, 45-60)months in 10 patients receiving other postoperative adjuvant therapy or without postoperative treatment, showing a significant difference between them ( χ2=4.21, P<0.05). Conclusion:The prognosis of patients of G3 nonfunctional pNETs with proliferation index of Ki-67<55% undergoing radical resection combined with postoperative comprehensive treatment based on CAPTEM chemotherapy in better than that of patients receiving other postoperative adjuvant therapy or without posto-perative treatment.

Pancreaticoduodenectomy (PD) is a major operation of abdominal surgery, with high risk, complex operation, more complications and high mortality. Pancreatic fistula is the main cause of death after PD. Due to its complexity and obstinacy, pancreatic fistula has become the top challenge of pancreatic surgery. The authors review the relevant literature and summarize the prevention and management of pancreatic fistula after PD, such as the optimization strategies for pancreatic anastomosis, the use of external stents, prophylactic drains in surgical field, the applica-tion of somatostatin and its analogues, and whole-course nutrition management, based on the precise and comprehensive opinion, in order to provide reference for improving the prevention and treatment of pancreatic fistula after PD.

Objective:To quantitatively evaluate the stiffness of pancreatic parenchyma and lesions by virtual touch tissue imaging and quantification (VTIQ) technique, and to investigate the potential usefulness of ultrasound shear wave elastography (SWE) in the prediction of clinically relevant post-operative pancreatic fistula (CR-POPF) after pancreatectomy.Methods:Patients who scheduled to receive pancreatectomy were prospectively enrolled in Zhongshan Hospital, Fudan University from March 2021 to December 2021. VTIQ assessment was applied to patients within one week before the scheduled surgery to make quantitative SWE evaluation of target tissue. The SWV values of body part pancreatic parenchyma and lesions were measured and recorded. The palpation stiffness of pancreas was qualitatively evaluated during the operation by the surgeon.CR-POPF was diagnosed according to 2016 International Study Group of Pancreatic Fistula (ISGPF) standard.Grade B/C pancreatic fistula was defined as CR-POPF positive. Recognized peri-operative risk factors of CR-POPF were analyzed. ROC curve analysis was used to evaluate the diagnostic efficacy of SWV value in predicting CR-POPF.Results:A total of 72 patients were finally enrolled in this study, including 47 (65.3%, 47/72) patients who received pancreaticoduodenectomy (PD) and 25 (34.7%, 25/72) patients who underwent distal pancreatectomy. CR-POPF occurred in 22 (30.6%, 22/72) patients after pancreatectomy. The SWV value of body part pancreatic parenchyma was significant lower in CR-POPF positive group than in CR-POPF negative group ( P<0.001). There was no significant difference in lesion SWV value between CR-POPF positive and negative groups ( P=0.664). Besides, the palpation stiffness was no difference between the two groups ( P=0.689). Taking SWV value of pancreatic parenchyma >1.16 m/s as a cut-off value for predicting CR-POPF, the area under the ROC curve (AUROC) was 0.816 with 0.760 of sensitivity, 0.634 of specificity, 67.5% of positive predictive value and 72.5% of negative predictive value, respectively. Conclusions:The VTIQ method may improve the objectivity and accuracy of CR-POPF prediction via pre-operative, non-invasive and quantitative evaluation of pancreatic stiffness, which has potential value in clinical applications.

BACKGROUND: Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting. METHODS: To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks. RESULTS: A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor. CONCLUSIONS Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.
Humans ; Male ; Retrospective Studies ; Diabetes Mellitus, Type 2/complications* ; Obesity, Morbid ; Anastomotic Leak/epidemiology* ; Gastrectomy/methods* ; Reoperation/methods* ; Registries ; Laparoscopy/methods* ; Treatment Outcome