Laparoscopic pancreaticoduodenectomy(LPD) poses a high risk of intraoperative bleeding due to the complex anatomy and rich blood supply in the pancreatic head region. This paper innovatively proposes a blood flow control technique system for LPD, adopting a strategy of “priority devascularization and pre-blocking”.By first addressing the peripheral collateral blood supply and the gastroduodenal artery, and then performing dual-system pre-blocking, the dorsal pancreatic artery and the inferior pancreaticoduodenal artery are treated in situ through a combined middle and left posterior approach. This progressive blood flow control method enhances surgical safety and oncological radicality, offering a new paradigm for the development of minimally invasive pancreatic surgery.

Laparoscopic pancreaticoduodenectomy(LPD) poses a high risk of intraoperative bleeding due to the complex anatomy and rich blood supply in the pancreatic head region. This paper innovatively proposes a blood flow control technique system for LPD, adopting a strategy of “priority devascularization and pre-blocking”.By first addressing the peripheral collateral blood supply and the gastroduodenal artery, and then performing dual-system pre-blocking, the dorsal pancreatic artery and the inferior pancreaticoduodenal artery are treated in situ through a combined middle and left posterior approach. This progressive blood flow control method enhances surgical safety and oncological radicality, offering a new paradigm for the development of minimally invasive pancreatic surgery.

Objective:To investigate the clinical effect of proper management of inferior pancreaticoduodenal artery (IPDA) in laparoscopic pancreaticoduodenectomy (LPD).Methods:This is a retrospective case series study. The clinical and pathological data of 70 patients who received LPD due to pancreatic head tumors, periampullary tumors, or distal common bile duct tumors in the Pancreatic Center of the Second Clinical College of Guangzhou University of Chinese Medicine from January to December 2022 were retrospectively collected. There were 47 males(67.1%) and 23 females(32.9%),aged (59.9±12.8)years(range:13 to 87 years).The procedure of IPDA exposure was as follows:a middle approach was utilized to expose the right half of superior mesenteric artery(SMA) and its right branches between the SMA and superior mesenteric vein(SMV) in superior colonic region. In the subcolonic region,SMA trunk exposure via dissection along the jejunal artery from feet to head and identification the association between IPDA and jejunal artery were prior to IPDA root ligation and dissection. The safety and efficacy of intraoperative IPDA handling were assessed based on surgical videos. Follow-up was carried out in outpatient clinic or by telephone, and outpatient follow-up was conducted once every 1 to 3 months after surgery.Results:The percentage of total LPD was 98.6%(69/70),with all patients achieving R0 resection. Nine cases(12.9%) were involved in combined vascular resection and reconstruction,with 1 case (1.4%) requiring additional upper abdominal incision for vascular and gastrointestinal reconstruction,while the remaining eight cases (11.4%) were completed laparoscopically. The operative time was (432.7±115.4)minutes(range:282 to 727 minutes), and the blood loss was (140.0±125.7)ml(range:20 to 800 ml). Only two patients(2.9%) received fresh frozen plasma transfusion,with an average volume of 650 ml. Reliable ligation and safe handling of the IPDA were achieved in 91.4%(64/70) of cases, with 8.6%(6/70) suffering from IPDA injury-related bleeding. No one was converted to opened surgery. Pathologically,the mean tumor size was (3.3±1.6)cm (range:1 to 7 cm),and the mean number of harvested lymph nodes was 17.0±7.3(range:0 to 46). Lymph node metastasis was observed in 13 cases (18.6%). Five cases (13.2%) developed grade B pancreatic fistula,while no grade C pancreatic fistula occurred. Other complications included bile leakage in one case(1.4%),delayed gastric emptying in two cases(2.9%), lymphatic leakage in 2 cases(2.9%),intra-abdominal infection in 9 cases(12.9%),and fat liquefaction of surgical incision in 1 case(1.4%). Two cases(2.9%) experienced postoperative intra-abdominal bleeding,one due to mesangial bleeding of lesser curvature of the stomach and the other due to oozing from the hepatic arterial sheath. These bleeding events were not concerned with IPDA. The average length of postoperative hospital stay was (15.2±4.6)days(range:9 to 28 days).Conclusion:Proper intraoperative management of IPDA in LPD might reduce IPDA-related bleeding during and after surgery and improve the safety of LPD.

Objective:To investigate the effect of estrogen supplementation therapy on vaginal microbiota and local immunity of postmenopausal high-risk human papillomavirus (HPV) infected women.Methods:A total of 74 postmenopausal women who underwent gynecological examinations or visits at Department of Gynecology, Shanghai Ruijin Rehabilitation Hospital from June 2018 to June 2023 were included in this study. According to HPV test, they were divided into the high-risk HPV-negative women (normal group, n=14) and the high-risk HPV-positive women ( n=60). A randomized controlled clinical trial was designed. Within the high-risk HPV-positive women, they were further randomly assigned by using the random number table method to the experimental group (high-risk HPV-positive women receiving low-dose estrogen therapy orally, n=30) and control group (high-risk HPV-positive women not receiving low-dose estrogen therapy, n=30). Vaginal microbiota composition and expression of inflammatory cytokines in vaginal lavage fluid were measured using fluorescence quantitative PCR and enzyme-linked immunosorbent assay at baseline (week 0), 4th week, and 8th week after enrollment. Results:There were no significant differences in age, menopausal time, body mass index, systolic pressure, diastolic pressure, heart rate, pH value and vaginal cell maturation index (VMI) among the normal group, the experimental group and control group (all P>0.05) which indicated the baseline was comparable. After estrogen treatment, the pH value of the experimental group at 4th and 8th weeks (5.27±0.13, 4.84±0.15) was significantly lower than that at week 0 (6.59±0.17, all P<0.001), while the vaginal cell maturation index (VMI) at 4th and 8th weeks (41.62±2.62, 58.28±2.16) was significantly higher than that at week 0 (25.97±2.60, all P<0.001). The quantitative results showed no significant differences in the abundance of Escherichia coli among the normal group, the experimental group, and control group, and within each group at different time points (all P>0.05). The abundance of Gardnerella and Atopobium in the experimental group was significantly higher at week 0 compared with 4th week and 8th week (all P<0.001). However, after estrogen treatment, the abundance of Gardnerella and Atopobium in the experimental group at 4th week was significantly lower than those in control group (all P<0.001), with no significant difference compared with the normal group (all P>0.05). There were no significant differences in the abundance of Prevotella, L. Gasseri, and L. Iners among the normal group, the experimental group, and control group at week 0, 4th week and 8th week (all P>0.05). The abundance of L. Crispatus and L. Jensenii in the experimental group and control group at week 0 was significantly lower than that in the normal group (all P<0.001). The abundance of L. Crispatus in the experimental group at 4th week and 8th week was significantly higher than that in control group (all P<0.001), with no significant difference compared with the normal group ( P>0.05). There were no significant differences in the concentrations of interleukin (IL)-6, IL-8, and interferon (IFN)-α in vaginal lavage fluid among the normal group, the experimental group, and control group (all P>0.05). The concentration of IL-1β in the experimental group and control group was significantly higher than that in the normal group ( P<0.001), with no significant difference between the experimental group and control group ( P>0.05). The concentration of tumor necrosis factor alpha (TNF-α) in the experimental group at 8th week was significantly lower than that at week 0 ( P<0.001), while there was no significant difference in TNF-α concentration after week 4 compared with week 0 ( P>0.05). Compared with the experimental group at week 0, the concentration of chemokine C-X-C motif ligand 14 (CXCL14) and IFN-β significantly decreased after 8 weeks of estrogen treatment (all P<0.001), with no significant change after 4 weeks of treatment ( P>0.05). Compared with the normal group, the concentration of IFN-γ inducible protein 16 in the experimental group and control group significantly increased (all P<0.001), with no significant difference between the experimental group and control group ( P>0.05). Conclusion:HPV infection can increase the abundance of Gardnerella and Atopobium in the vagina of postmenopausal women and decrease the abundance of L. Crispatus and L. Jensenii, which further disrupts the homeostasis of microorganisms in the vaginal microenvironment. Estrogen replacement therapy has a certain improvement effect on vaginal flora and local immunity in postmenopausal women with high-risk HPV infection.

Objective:To investigate the effect of estrogen supplementation therapy on vaginal microbiota and local immunity of postmenopausal high-risk human papillomavirus (HPV) infected women.Methods:A total of 74 postmenopausal women who underwent gynecological examinations or visits at Department of Gynecology, Shanghai Ruijin Rehabilitation Hospital from June 2018 to June 2023 were included in this study. According to HPV test, they were divided into the high-risk HPV-negative women (normal group, n=14) and the high-risk HPV-positive women ( n=60). A randomized controlled clinical trial was designed. Within the high-risk HPV-positive women, they were further randomly assigned by using the random number table method to the experimental group (high-risk HPV-positive women receiving low-dose estrogen therapy orally, n=30) and control group (high-risk HPV-positive women not receiving low-dose estrogen therapy, n=30). Vaginal microbiota composition and expression of inflammatory cytokines in vaginal lavage fluid were measured using fluorescence quantitative PCR and enzyme-linked immunosorbent assay at baseline (week 0), 4th week, and 8th week after enrollment. Results:There were no significant differences in age, menopausal time, body mass index, systolic pressure, diastolic pressure, heart rate, pH value and vaginal cell maturation index (VMI) among the normal group, the experimental group and control group (all P>0.05) which indicated the baseline was comparable. After estrogen treatment, the pH value of the experimental group at 4th and 8th weeks (5.27±0.13, 4.84±0.15) was significantly lower than that at week 0 (6.59±0.17, all P<0.001), while the vaginal cell maturation index (VMI) at 4th and 8th weeks (41.62±2.62, 58.28±2.16) was significantly higher than that at week 0 (25.97±2.60, all P<0.001). The quantitative results showed no significant differences in the abundance of Escherichia coli among the normal group, the experimental group, and control group, and within each group at different time points (all P>0.05). The abundance of Gardnerella and Atopobium in the experimental group was significantly higher at week 0 compared with 4th week and 8th week (all P<0.001). However, after estrogen treatment, the abundance of Gardnerella and Atopobium in the experimental group at 4th week was significantly lower than those in control group (all P<0.001), with no significant difference compared with the normal group (all P>0.05). There were no significant differences in the abundance of Prevotella, L. Gasseri, and L. Iners among the normal group, the experimental group, and control group at week 0, 4th week and 8th week (all P>0.05). The abundance of L. Crispatus and L. Jensenii in the experimental group and control group at week 0 was significantly lower than that in the normal group (all P<0.001). The abundance of L. Crispatus in the experimental group at 4th week and 8th week was significantly higher than that in control group (all P<0.001), with no significant difference compared with the normal group ( P>0.05). There were no significant differences in the concentrations of interleukin (IL)-6, IL-8, and interferon (IFN)-α in vaginal lavage fluid among the normal group, the experimental group, and control group (all P>0.05). The concentration of IL-1β in the experimental group and control group was significantly higher than that in the normal group ( P<0.001), with no significant difference between the experimental group and control group ( P>0.05). The concentration of tumor necrosis factor alpha (TNF-α) in the experimental group at 8th week was significantly lower than that at week 0 ( P<0.001), while there was no significant difference in TNF-α concentration after week 4 compared with week 0 ( P>0.05). Compared with the experimental group at week 0, the concentration of chemokine C-X-C motif ligand 14 (CXCL14) and IFN-β significantly decreased after 8 weeks of estrogen treatment (all P<0.001), with no significant change after 4 weeks of treatment ( P>0.05). Compared with the normal group, the concentration of IFN-γ inducible protein 16 in the experimental group and control group significantly increased (all P<0.001), with no significant difference between the experimental group and control group ( P>0.05). Conclusion:HPV infection can increase the abundance of Gardnerella and Atopobium in the vagina of postmenopausal women and decrease the abundance of L. Crispatus and L. Jensenii, which further disrupts the homeostasis of microorganisms in the vaginal microenvironment. Estrogen replacement therapy has a certain improvement effect on vaginal flora and local immunity in postmenopausal women with high-risk HPV infection.

Objective:To investigate the clinical effect of proper management of inferior pancreaticoduodenal artery (IPDA) in laparoscopic pancreaticoduodenectomy (LPD).Methods:This is a retrospective case series study. The clinical and pathological data of 70 patients who received LPD due to pancreatic head tumors, periampullary tumors, or distal common bile duct tumors in the Pancreatic Center of the Second Clinical College of Guangzhou University of Chinese Medicine from January to December 2022 were retrospectively collected. There were 47 males(67.1%) and 23 females(32.9%),aged (59.9±12.8)years(range:13 to 87 years).The procedure of IPDA exposure was as follows:a middle approach was utilized to expose the right half of superior mesenteric artery(SMA) and its right branches between the SMA and superior mesenteric vein(SMV) in superior colonic region. In the subcolonic region,SMA trunk exposure via dissection along the jejunal artery from feet to head and identification the association between IPDA and jejunal artery were prior to IPDA root ligation and dissection. The safety and efficacy of intraoperative IPDA handling were assessed based on surgical videos. Follow-up was carried out in outpatient clinic or by telephone, and outpatient follow-up was conducted once every 1 to 3 months after surgery.Results:The percentage of total LPD was 98.6%(69/70),with all patients achieving R0 resection. Nine cases(12.9%) were involved in combined vascular resection and reconstruction,with 1 case (1.4%) requiring additional upper abdominal incision for vascular and gastrointestinal reconstruction,while the remaining eight cases (11.4%) were completed laparoscopically. The operative time was (432.7±115.4)minutes(range:282 to 727 minutes), and the blood loss was (140.0±125.7)ml(range:20 to 800 ml). Only two patients(2.9%) received fresh frozen plasma transfusion,with an average volume of 650 ml. Reliable ligation and safe handling of the IPDA were achieved in 91.4%(64/70) of cases, with 8.6%(6/70) suffering from IPDA injury-related bleeding. No one was converted to opened surgery. Pathologically,the mean tumor size was (3.3±1.6)cm (range:1 to 7 cm),and the mean number of harvested lymph nodes was 17.0±7.3(range:0 to 46). Lymph node metastasis was observed in 13 cases (18.6%). Five cases (13.2%) developed grade B pancreatic fistula,while no grade C pancreatic fistula occurred. Other complications included bile leakage in one case(1.4%),delayed gastric emptying in two cases(2.9%), lymphatic leakage in 2 cases(2.9%),intra-abdominal infection in 9 cases(12.9%),and fat liquefaction of surgical incision in 1 case(1.4%). Two cases(2.9%) experienced postoperative intra-abdominal bleeding,one due to mesangial bleeding of lesser curvature of the stomach and the other due to oozing from the hepatic arterial sheath. These bleeding events were not concerned with IPDA. The average length of postoperative hospital stay was (15.2±4.6)days(range:9 to 28 days).Conclusion:Proper intraoperative management of IPDA in LPD might reduce IPDA-related bleeding during and after surgery and improve the safety of LPD.

Objective:To study the preliminary clinical results of the No-touch technique in laparoscopic pancreaticoduodenectomy for pancreatic head cancer.Methods:A retrospective analysis was consulted on 11 patients who underwent laparoscopic pancreaticoduodenectomy for pancreatic head cancer at the Pancreas Center of Guangdong Provincial Hospital of Traditional Chinese Medicine from April 2019 to April 2020. There were 5 males and 6 females, with a Mean±SD age of (63.6±12.2) years. Preoperative evaluation showed all patients were diagnosed to have resectable pancreatic head carcinoma with no local invasion into adjacent arteries and veins, and without metastasis. The surgical strategy consisted of no initial Kocher manoeuvre with no flipping or pulling of the pancreaticoduodenal area. Through unwinding of the pancreatic uncinate process, the pancreatic blood vessels, nerves and lymphatic vessels were completely detached to isolate the tumor. Finally, the pancreaticoduodenal area was totally resected and the digestive tract was reconstructed using the Child’s method. The operation time, intraoperative blood loss, postoperative complications, postoperative pathology and follow-up data of the patients were evaluated.Results:All patients completed the laparoscopic operation without any need for conversion to laparotomy. The operation time of the 11 patients was (422.2±102.2) min, and the bleeding volume was (102.7±65.4) ml. There were 2 patients who developed pancreatic fistula, with 1 patient having a biochemical fistula and 1 patient a grade B fistula. There was no grade C fistula. Other complications included 1 patient with delayed gastric emptying. There were no biliary fistula, no postoperative abdominal bleeding, and no perioperative death. Postoperative pathology showed 6 patients had lymph node metastases, with a positive lymph nodes rate of (4.8±4.4)%. All patients had R 0 resection. The follow-up survival data of the 11 patients showed one patient to develop intrahepatic metastasis 1 month after operation and he died 9 months after operation. Another patient developed liver metastases 2 months after operation. The remaining patients were tumor-free. Conclusion:Laparoscopic pancreaticoduodenectomy using the No-touch isolation and resection technique could achieve complete resection of tumors, and it can safely and effectively be applied to patients with pancreatic head cancer.

Pancreaticoduodenectomy is one of the most difficult abdominal operations, and the difficulty in resection and complicated digestive tract reconstruction have brought great challenges for surgeons. At present, laparoscopic pancreaticoduodenectomy has been widely used in clinical practice, and compared with traditional 2D laparoscopy, 3D laparoscopy has the features of high magnification, high definition, and three-dimensional vision, which enables surgeons to see more clearly and operate more accurately, and thus it has great potential to be widely used in pancreaticoduodenectomy.

Objective:To examine the surgical approach, practical cognition as well as clinical effect of the orthotopic resection for laparoscopic pancreatoduodenectomy(OLPD).Methods:From March 2019 to December 2019, 32 cases were treated with laparoscopic pancreatoduodenectomy (LPD) in a novel approach without mobilization of pancreatoduodenum in Pancreas Center of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine.There were 16 male patients and 16 female patients.The mean age was (64.8±9.5) years old.Body mass index was 14.9 to 31.0 kg/m 2.All patients were diagnosed as ampullary or pancreatic head tumors and were not unresectable cases.In the surgical strategy, Kocher′s dissociation, turning and pulling of the pancreaticoduodenal region, was not performed first.Anatomy in situ, separation of vessels which enter and exit from pancreas, separation of lymphatics and isolation of tumors were carried out in priority through the combined middle and left posterior approaches.Finally, the pancreatic head and duodenum region was mobilized and the entire resection of pancreas in situ was carried out.Digestive tract reconstruction was performed through Child method. Results:Postoperative pathology showed that 27 cases were pancreatic or ampullary malignant tumors and five cases were benign tumors among 32 patients.The operative time was (357.3±64.3) minutes.The diameter of pancreatic ducts was (3.0±1.0) mm. The pancreas of 20 cases (62.5%) were soft. Five patients suffered from pancreatic fistula (Grade B) and one patient suffered from intra-abdominal hemorrhage postoperatively.No other complications like pancreatic fistula (Grade C) or biliary fistula delayed gastric emptying or mortality were encountered.The postoperative hospital day was (13.7±3.6) days.Conclusions:Combining the multi-angle of the laparoscopic approaches and excising the pancreaticoduodenal specimen in situ, OLPD is a kind of surgical method which can realize the concept of no touch tumor surgery.Patients who undergo the OLPD can receive better treatments and results.

Objective:To examine the surgical approach, practical cognition as well as clinical effect of the orthotopic resection for laparoscopic pancreatoduodenectomy(OLPD).Methods:From March 2019 to December 2019, 32 cases were treated with laparoscopic pancreatoduodenectomy (LPD) in a novel approach without mobilization of pancreatoduodenum in Pancreas Center of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine.There were 16 male patients and 16 female patients.The mean age was (64.8±9.5) years old.Body mass index was 14.9 to 31.0 kg/m 2.All patients were diagnosed as ampullary or pancreatic head tumors and were not unresectable cases.In the surgical strategy, Kocher′s dissociation, turning and pulling of the pancreaticoduodenal region, was not performed first.Anatomy in situ, separation of vessels which enter and exit from pancreas, separation of lymphatics and isolation of tumors were carried out in priority through the combined middle and left posterior approaches.Finally, the pancreatic head and duodenum region was mobilized and the entire resection of pancreas in situ was carried out.Digestive tract reconstruction was performed through Child method. Results:Postoperative pathology showed that 27 cases were pancreatic or ampullary malignant tumors and five cases were benign tumors among 32 patients.The operative time was (357.3±64.3) minutes.The diameter of pancreatic ducts was (3.0±1.0) mm. The pancreas of 20 cases (62.5%) were soft. Five patients suffered from pancreatic fistula (Grade B) and one patient suffered from intra-abdominal hemorrhage postoperatively.No other complications like pancreatic fistula (Grade C) or biliary fistula delayed gastric emptying or mortality were encountered.The postoperative hospital day was (13.7±3.6) days.Conclusions:Combining the multi-angle of the laparoscopic approaches and excising the pancreaticoduodenal specimen in situ, OLPD is a kind of surgical method which can realize the concept of no touch tumor surgery.Patients who undergo the OLPD can receive better treatments and results.