Background and Aims:Laparoscopic pancreaticoduodenectomy(LPD)is one of the most technically demanding procedures in general surgery.Its development remains controversial,particularly regarding adherence to oncological principles.In situ LPD,based on the"no-touch"principle,offers a treatment option for pancreatic tumors.However,ensuring surgical safety remains a key challenge due to its technical complexity.This study explored the surgical techniques of in situ LPD performed via the left-sided combined middle approach and evaluated its safety and efficacy.Methods:A retrospective analysis was conducted on the clinical data of four patients who underwent in situ LPD using the left-sided combined middle approach between July 2023 and November 2023 at the Department of Pancreatic Surgery of Fudan University Shanghai Cancer Center and the Department of Hepatobiliary Surgery of Yijishan Hospital,Wannan Medical College.Results:All 4 patients were female,with an average age of 58 and a mean BMI of 22.1 kg/m2.Among them,two had pancreatic head cancer,one had ampullary carcinoma,and one had distal common bile duct carcinoma.Preoperative laboratory indicators,including white blood cell count,platelet count,prothrombin time,alanine aminotransferase,aspartate aminotransferase,albumin,total bilirubin,and direct bilirubin,were all within normal ranges.All patients successfully underwent in situ LPD via the left-sided combined middle approach.The mean operative time was 385 min,with an average intraoperative blood loss of 87.5 mL.After operation,the average drainage tube removal time was 10.3 d,and the mean hospital stay was 10.8 d.One patient developed biochemical leakage,and another experienced abdominal effusion,while no cases of biliary stricture,diarrhea,or chylous leakage were observed.Conclusion:In situ LPD via the left-sided combined middle approach allows for thorough lymph node dissection and radical tumor resection while adhering to the"no-touch"principle.This approach is simple to perform and master and does not lead to significant postoperative complications.It is a safe and feasible technique with promise for broader clinical application.Future research should focus on multicenter studies with larger sample sizes to validate its safety and efficacy.

Background and Aims:Laparoscopic pancreaticoduodenectomy(LPD)is one of the most technically demanding procedures in general surgery.Its development remains controversial,particularly regarding adherence to oncological principles.In situ LPD,based on the"no-touch"principle,offers a treatment option for pancreatic tumors.However,ensuring surgical safety remains a key challenge due to its technical complexity.This study explored the surgical techniques of in situ LPD performed via the left-sided combined middle approach and evaluated its safety and efficacy.Methods:A retrospective analysis was conducted on the clinical data of four patients who underwent in situ LPD using the left-sided combined middle approach between July 2023 and November 2023 at the Department of Pancreatic Surgery of Fudan University Shanghai Cancer Center and the Department of Hepatobiliary Surgery of Yijishan Hospital,Wannan Medical College.Results:All 4 patients were female,with an average age of 58 and a mean BMI of 22.1 kg/m2.Among them,two had pancreatic head cancer,one had ampullary carcinoma,and one had distal common bile duct carcinoma.Preoperative laboratory indicators,including white blood cell count,platelet count,prothrombin time,alanine aminotransferase,aspartate aminotransferase,albumin,total bilirubin,and direct bilirubin,were all within normal ranges.All patients successfully underwent in situ LPD via the left-sided combined middle approach.The mean operative time was 385 min,with an average intraoperative blood loss of 87.5 mL.After operation,the average drainage tube removal time was 10.3 d,and the mean hospital stay was 10.8 d.One patient developed biochemical leakage,and another experienced abdominal effusion,while no cases of biliary stricture,diarrhea,or chylous leakage were observed.Conclusion:In situ LPD via the left-sided combined middle approach allows for thorough lymph node dissection and radical tumor resection while adhering to the"no-touch"principle.This approach is simple to perform and master and does not lead to significant postoperative complications.It is a safe and feasible technique with promise for broader clinical application.Future research should focus on multicenter studies with larger sample sizes to validate its safety and efficacy.

Objective:To analyze the application of indocyanine green (ICG) fluorescence imaging in laparoscopic resection of pancreatic cancer.Methods:Data of 15 patients undergoing laparoscopic surgery for pancreatic cancer in the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Wannan Medical College from June 2022 to March 2023 were retrospectively analyzed, including 13 males and 2 females, aged (67.0±8.6) years. ICG were intraoperatively injected to visualize the lesion and guide surgical resection. The surgical methods, postoperative pathology, ICG fluorescence imaging and tumor margins were reviewd.Results:Among the patients, seven underwent laparoscopic pancreaticoduodenectomy, seven underwent laparoscopic radical antegrade modular pancreaticosplenectomy, and one conversed to open pancreaticoduodenectomy due to combined superior mesenteric vein reconstruction. Postoperative pathology confirmed pancreatic moderately differentiated adenocarcinoma in nine cases, pancreatic moderately-low differentiated adenocarcinoma in four cases, pancreatic follicular cell carcinoma in one case, and inflammatory lesion in one case. Negative surgical margins were confirmed in all cases. Pancreatic lesion were visualized in 14 cases (fluorescent delineation of the tumor capsule) but not well visualized in one case (with moderately differentiated adenocarcinoma). In the case of inflammatory disease, the lesion parenchyma were visualized.Conclusion:ICG injection in laparoscopic surgery enables visualization of pancreatic tumor, which facilitates tumor localization and margin determination.

Objective:To evaluate the efficacy of a modified continuous penetrating-suture pancreaticojejunostomy (PPJ), also known as a continuous PPJ with a U-shaped reinforcement of pancreatic section (U-PPJ), in patients with high risk of clinically relevant postoperative pancreatic fistula (CR-POPF).Methods:Clinical data of 33 patients with pancreatic tumors undergoing pancreatic surgery in the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Wannan Medical College from August 2017 to December 2023 were collected, including 22 males and 11 females, aged (64.9±8.6) years old. According to the fashion of pancreaticojejunostomy, patients were divided into two groups: U-PPJ group ( n=11) and PPJ group ( n=22). The general data, incidence of CR-POPF, abdominal bleeding and other clinicopathological data were collected. Results:All patients underwent pancreatic surgery successfully and were discharged from the hospital uneventfully. Intraoperative blood loss in U-PPJ group was 200.00 (100.0, 200.0) ml, postoperative hospitalization was 13.0 (11.0, 18.0) d, and the drain removal time was 17.0 (12.0, 21.0) d, and no CR-POPF occurred. The intraoperative blood loss, postoperative hospitalization days, drain removal time, and incidence of postoperative biochemical leakage were comparable between the groups (all P>0.05). The incidence of CR-POPF in U-PPJ group was lower than that in PPJ group [0 vs. 22.7% (5/22), P<0.05]. Conclusion:U-PPJ is safe and effective in patients with pancreatic tumors and might reduce the incidence of CR-POPF.

Objective:To analyze the risk factors of clinically-relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) and penetrating pancreaticojejunostomy (PPJ).Methods:The clinical data of 108 patients who underwent PD and PPJ in the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Wannan Medical College from January 2017 to October 2022 were analyzed retrospectively, including 65 males and 43 females, aged 65.5 (54.2, 72.0) years. The incidences of POPF, biliary fistula, abdominal bleeding and other related complications were reviewed. The related factors of CR-POPF were analyzed by univariate analysis, and the statistically significant factors were included in multivariate logistic regression analysis.Results:A total of 108 patients were successfully treated with PD, including laparoscopic PD in 76 cases (70.4%) and open PD in 32 cases (29.6%). PPJ was performed in PD, including the continuous fashion in 39 cases (36.1%), intermittent fashion in 49 cases (45.4%) and modified continuous fashion in 20 cases (18.5%). The operation time was 390.0 (314.0, 480.0) min, the intraoperative blood loss was 200.0 (100.0, 384.0) ml, the postoperative hospital stay was 12.0 (10.0, 15.0) d, and the incidence of POPF (grade B + C) was 11.1% (12/108). Body mass index, pancreatic CT value and pancreatic duct size were the significant factors of CR-POPF (all P<0.05). Multivariate logistic regression analysis showed that age ( OR=0.895, 95% CI: 0.822-0.975), pancreatic CT value ( OR=0.812, 95% CI: 0.698-0.946) and pancreatic duct size ( OR=0.457, 95% CI: 0.220-0.952) were risk factors of CR-POPF after PPJ (all P<0.05). Conclusion:PPJ is a safe method of pancreaticoenterostomy, and CR-POPF may be related to younger patients, lower pancreatic CT value and the smaller pancreatic duct size.

Objective To analyze the characteristics of dynamic contrast enhanced MR imaging (DCE-MRI)in prostate cancer (PCa)at 3.0T,and to evaluate the diagnostic value of DCE-MRI.Methods 85 patients with suepected PCa received conventional MRI and DCE-MRI.The signal intense-time (SI-T)curve was analyzed.Then the time to maximum (Tmax),the maximum degree of enhancement (STmax%),and the rate of enhancement (Rmax)were calculated.The differences of styles of SI-T curve and the parameters between the positive and negative group were compared respectively.Results 59 cases of PCa were proved by biopsy,and there was no evidence of tumor in 26 cases.507 zones had histopathological results with 250 zones in positive group and 257 zones in negative group .The most common style of SI-T curve in positive group was rapidly ascending followed with descending curve,the most common style of SI-T curve in negative group was persistent ascending curve and plateau curve.The mean values of Tmax,SImax%,Rmax were (69.49±22.53)s,1.74±0.43,7.83±3.80 in positive group respectively,while (175.61±52.64)s,1.05±0.35,1.86±1.10 in negative group respectively,there were statistically significant differences between the two groups(t =-24.24,1 6.34,1 7.75,P <0.01)respectively. The mean values of Tmax,SImax% ,Rmax were (8 9 .1 9 ± 3 1 .7 2 )s,1 .5 8 ± 0 .4 6 ,5 .2 1 ± 3 .3 4 in the low-risk group (Gleason score 2 - 6 )respectively,while (64.25±14.68)s,1.76±0.43,8.25±3.70 in the high-risk group (Gleason score 7-10)respectively, there were statistically significant differences between them(t = 7.09,-8.74,- 7.83,P <0.01).Conclusion 3.0T DCE-MRI has great value in the diagnosis of PCa.

Objective To summarize radiographic manifestations of granulocytic sarcoma (GS),in order to investigate its radio-graphic feature.Methods Nine patients of GS confirmed by surgery pathology and immunohistochemistry were collected.There were four cases underwent CT scan,2 underwent MRI,3 underwent CT and MRI meanwhile.Results There were 4 cases in the lymph nodes,4 cases in the bone,1 case in the enterocoelia.The density of enlarged lymph node was inhomogeneous,and smaller lymph node was homogeneous density,both enhanced obviously.The density or intensity of the lesions occurred in the canalis verteb-ralis and paravertebra was also homogeneous,slightly enhanced,with bone and medulla ossea invasion.Lesions in the enterocoelia was inhomogeneous desity with clear boundary,enhanced inhomogeneously.Conclusion GS is a rare extramedullary malignant tumor composed of immature myeloid cells.CT and MRI can provide a certain diagnostic value.The perplexity in diagnosing such lesions highlighted the need of careful interpretation of all clinacal,radiographic,histopathological and immunochistochemical details as it is one of the most frequently misdiagnosed disorder.

Objective To evaluate mono-and bi-exponential decay models in the diagnosis of hepatocellular carcinoma (HCC). Methods 28 patients with HCC who underwent conventional MRI imaging and diffusion-weighted imaging were collected,and all the HCC lesions were proved by operation pathology.The ADC values in mono-exponential decay model and ADCst ,ADCslow , ADCfast and ffast of the lesions in bi-exponential decay model were measured through the reconstruction of ADCmap ,ADCslow map, ADCfast map and fraction of fast ADC at a workstation.The relationships between the ADC values with low,medium and high b-val-ues and different differentiation degrees of HCC were analyzed.Moreover,the relationships between the ADCst ,ADCslow ,ADCfast , ffast values and HCC defferentiation grades were also explored.Results Significant differences in ADC value were found among differ-ent degrees of HCC differentiation in middle and high b-value groups (P <0.05).A positive correlation was found between the ADC value and the degree of HCC differentiation in middle (r=0.377,P <0.01)and high b-value group (r =0.81 5,P <0.01).There were no significant differences in ADC value among the different degrees of HCC differentiation in low b-value group.There were significant differences in the values of ADCst ,ADCslow and ADCfast among different degrees of HCC differentiation.Significant posi-tive correlations were found between the values of ADCst ,ADCslow and ADCfast and the degree of differentiation (P <0.01).There were no significant differences in the values of ffast among different degrees of HCC differentiation.Conclusion ADC value in mono-exponential decay model plays a potential role in the diagnosis of different differentiation degree of HCC with a b value ≥400 s/mm2 .Furthermore,the parameters in bi-exponential decay model,especially the values of ADCst ,ADCslow and ADCfast ,can provide new and unique information in the distinction of different degrees of HCC differentiation.

Objective To improve the diagnostic accuracy by analyzing the CT features of primary hepatic sarcoma.Methods The CT findings of 6 cases with primary hepatic sarcoma confirmed by histopathology were analyzed retrospectively,including primary hepatic angiosarcoma 2 cases,and epithelioid hemangioendothelioma,primary hepatic lymphoma,alveolar soft-part sarcoma,undif-ferentiated embryonal sarcoma,1 case each.Results Primary hepatic sarcoma appeared as multiple nodules with heterogeneous and progressive enhencement in one case,and a dominant mass with multiple satellite nodules in another case.Epithelioid hemangioendo-thelioma displayed as multifocal hepatic disease involving both liver lobes,more than half of the lesions were peripheral and extended to the liver margin.Primary hepatic lymphoma demonstrated as an ill-defined low-density lesion with irregular ring enhancement. Alveolar soft-part sarcoma presented as a well-defined low-density lesion with obviously heterogeneous enhancement in arterial phase.Undifferentiated embryonal sarcoma appeared as a huge cystic lesion with slightly margin enhancement.Conclusion The CT findings of primary hepatic sarcoma are associated with the pathological types,combining clinical symptoms with typical CT features are helpful to the diagnosis.The ultimate diagnosis relies on pathology and immune histochemistry.

Objective To study the relationship between hepatic arterial buffer response (HABR),recovery of liver function,early biliary complications and small-for-size syndrome (SFSS).Methods Early hepatic hemodynamic parameters (including hepatic arterial flow (HAF),portal venous flow (PVF) were measured using duplex Doppler sonography in 34 patients who received living donor liver transplantation (preoperatively n＝26,intraoperatively n=26) and on postoperative days 1,2,3,and 7.Alanine aminotransferase (ALT),aspartate aminotransferase (AST) and total bilirubin (TBIL) level were measured preoperatively and on postoperative days 1,2,3,7,14,21,and 28.If TBIL level was elevated,we used B ultrasonography or CT and even ERCP to diagnose early biliary complications.The days taken for AST,AI T and TBIL to recover and the number of patients with early (＜60 days) biliary complications (bile leakage or bile stricture) and with small-for-size syndrome (SFSS) were recorded.Results Passive hepatic artery buffer response (HABR) was present in 11 patients early after living donor liver transplantation (group 1) and it disappeared in 23 patients (group 2).The recovery in days taken for normalization of AST (10.6± 8.8),AIT (11.6±9.0) and TBlL (average of 29) in group 1 were shorter than in group 2.However,the differences did not reach statistics difference (P＞0.05).The overall incidences of early biliary complications and small-for-size syndrome (SFSS) in group 1 were significantly lower than in group 2 (P=0.04).The survival rate in group 1 was 82 ％,compared with 74 ％ in group 2.Conclusions Passive hepatic arterial buffer response (HABR) disappeared in some patients early after living donor liver transplantation.There were high incidences of early biliary complications and small-for-size syndrome (SFSS) in these patients.Measurcment of hepatic buffer response in the early stage after living donor liver tranaplanta tion is valuable for predition of early biliary complications and small-for-size syndrome (SFSS),thus helping to prevent failure in transplantation.