Objective:To construct an ensemble machine learning model for predicting the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy and evaluate its application value.Methods:This is a research on predictive model. Clinical data of 421 patients undergoing pancreaticoduodenectomy in the Department of Pancreatic Surgery,Union Hospital, Tongji Medical College,Huazhong University of Science and Technology from June 2020 to May 2023 were retrospectively collected. There were 241 males (57.2%) and 180 females (42.8%) with an age of (59.7±11.0)years (range: 12 to 85 years).The research objects were divided into training set (315 cases) and test set (106 cases) by stratified random sampling in the ratio of 3∶1. Recursive feature elimination is used to screen features,nine machine learning algorithms are used to model,three groups of models with better fitting ability are selected,and the ensemble model was constructed by Stacking algorithm for model fusion. The model performance was evaluated by various indexes,and the interpretability of the optimal model was analyzed by Shapley Additive Explanations(SHAP) method. The patients in the test set were divided into different risk groups according to the prediction probability (P) of the alternative pancreatic fistula risk score system (a-FRS). The a-FRS score was validated and the predictive efficacy of the model was compared.Results:Among 421 patients,CR-POPF occurred in 84 cases (20.0%). In the test set,the Stacking ensemble model performs best,with the area under the curve (AUC) of the subject′s work characteristic curve being 0.823,the accuracy being 0.83,the F1 score being 0.63,and the Brier score being 0.097. SHAP summary map showed that the top 9 factors affecting CR-POPF after pancreaticoduodenectomy were pancreatic duct diameter,CT value ratio,postoperative serum amylase,IL-6,body mass index,operative time,albumin difference before and after surgery,procalcitonin and IL-10. The effects of each feature on the occurrence of CR-POPF after pancreaticoduodenectomy showed a complex nonlinear relationship. The risk of CR-POPF increased when pancreatic duct diameter<3.5 mm,CT value ratio<0.95,postoperative serum amylase concentration>150 U/L,IL-6 level>280 ng/L,operative time>350 minutes,and albumin decreased by more than 10 g/L. The AUC of a-FRS in the test set was 0.668,and the prediction performance of a-FRS was lower than that of the Stacking ensemble machine learning model.Conclusion:The ensemble machine learning model constructed in this study can predict the occurrence of CR-POPF after pancreaticoduodenectomy,and has the potential to be a tool for personalized diagnosis and treatment after pancreaticoduodenectomy.

Objective:To construct an ensemble machine learning model for predicting the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy and evaluate its application value.Methods:This is a research on predictive model. Clinical data of 421 patients undergoing pancreaticoduodenectomy in the Department of Pancreatic Surgery,Union Hospital, Tongji Medical College,Huazhong University of Science and Technology from June 2020 to May 2023 were retrospectively collected. There were 241 males (57.2%) and 180 females (42.8%) with an age of (59.7±11.0)years (range: 12 to 85 years).The research objects were divided into training set (315 cases) and test set (106 cases) by stratified random sampling in the ratio of 3∶1. Recursive feature elimination is used to screen features,nine machine learning algorithms are used to model,three groups of models with better fitting ability are selected,and the ensemble model was constructed by Stacking algorithm for model fusion. The model performance was evaluated by various indexes,and the interpretability of the optimal model was analyzed by Shapley Additive Explanations(SHAP) method. The patients in the test set were divided into different risk groups according to the prediction probability (P) of the alternative pancreatic fistula risk score system (a-FRS). The a-FRS score was validated and the predictive efficacy of the model was compared.Results:Among 421 patients,CR-POPF occurred in 84 cases (20.0%). In the test set,the Stacking ensemble model performs best,with the area under the curve (AUC) of the subject′s work characteristic curve being 0.823,the accuracy being 0.83,the F1 score being 0.63,and the Brier score being 0.097. SHAP summary map showed that the top 9 factors affecting CR-POPF after pancreaticoduodenectomy were pancreatic duct diameter,CT value ratio,postoperative serum amylase,IL-6,body mass index,operative time,albumin difference before and after surgery,procalcitonin and IL-10. The effects of each feature on the occurrence of CR-POPF after pancreaticoduodenectomy showed a complex nonlinear relationship. The risk of CR-POPF increased when pancreatic duct diameter<3.5 mm,CT value ratio<0.95,postoperative serum amylase concentration>150 U/L,IL-6 level>280 ng/L,operative time>350 minutes,and albumin decreased by more than 10 g/L. The AUC of a-FRS in the test set was 0.668,and the prediction performance of a-FRS was lower than that of the Stacking ensemble machine learning model.Conclusion:The ensemble machine learning model constructed in this study can predict the occurrence of CR-POPF after pancreaticoduodenectomy,and has the potential to be a tool for personalized diagnosis and treatment after pancreaticoduodenectomy.

Objective: To explorethe proper protective measures for pancreaticdiseases treatment during theoutbreak of 2019 coronavirus disease(COVID-19). Method: Clinical data of four cases of patients that suffered COVID-19from February 2^nd, 2020 to February 9^th, 2020 in pancreatic surgery were reviewed.After the first patientscuffednosocomial infection of COVID-19, the general protective measures in our department wereupdated.Only one patient was admitted to each room alone, with no more than one caregiver.The body temperature of care givers was measuredtwice a day.Primary protections were applied to all staff.The floor was sterilized using disinfectant with an effective chlorine concentration of 1000 mg/L.The protective measures for interventional procedures were as follow.Primary protection was applied to the operators ofcentral venipuncture catheter, percutaneous abdominal/pleural drainage, percutaneous retroperitoneal drainage, percutaneous transhepatic cholangial drainage and other surgical procedures with local anesthesiaand epidural anesthesia.Secondary protection was applied to the operators of endoscopic retrograde cholangiopancreatography and surgical procedures with general anesthesia. Results: During Feb 2^nd, 2020 to Feb 9^th, 2020, four patients in our department were diagnosed with COVID-19, of which one was died of COVID-19, two were cured, and one is still in hospital for COVID-19.After the update ofprotective measures in our department, no more nosocomial infection of COVID-19occurred.Two central venipuncture catheter, three percutaneous abdominal/pleural drainage, one percutaneous retroperitoneal drainage, one percuteneous transhepatic cholecyst drainage and one open surgery with general anesthesia were performed with no infection of operators. Conclusions The caregivers of patients are potential infection source of COVID-19.Enhanced protective measures including the management measures of caregivers can decrease the risk of nosocomial infection of COVID-19.

Objective: To investigate the changes of surgical invitations on necrotizing pancreatitis in recent 14 years by reviewing single center data. Methods: One thousand and eighty patients with necrotizing pancreatitis who received surgical invitation were involved in the study.All the patients were treated at Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2005 to December 2018. Six hundred and seventy-eight were males and 402 were females. The median (range) age of the study patients was 45 (20-76) years.The etiology of the disease was related to cholelithiasis in 335 cases(31.02%), hyperlipemia in 302 cases(27.96%), alcohol in 226 cases(20.93%), endoscopic retrograde cholangiopancreatography in 28 cases(2.59%), pregnancy in 50 cases(4.63%), idiopathic factors in 72 cases(6.67%) and other causes in 67 cases(6.20%). The patients were divided into two groups according to the time of admission. Group 1 included 1 475 patients that admitted from January 2005 to December 2010, and group 2 included 1 539 patients that admitted from January 2011 to December 2018. The surgical interventions, morbidity and mortality of the two group were compared, and χ² test was used for the statistical test. Results: Two hundred and sixty-six among the 1 080 cases were treated with drainage procedures because of the pseudocyst.One hundred and seventy-five drainage procedures were performed between January 2005 and December 2018, which account for 11.87%(175/1 475) of all patients of necrotizing pancreatitis; 91 drainage procedures were performed between January 2011 and December 2018, which account for 5.91%(91/1 539) of all patients of necrotizing pancreatitis. Eight hundred and fourteen cases received surgical intervention for infection of necrotizing tissues. Of these cases, 410 cases received percutaneous catheter drainage(PCD) of retroperitoneal fluid or residual infection. Debridement of necrotic tissues was performed on 756 cases. Of these cases, 32 cases received minimal invasive retroperitoneal debridement with/without denotes video assistant, 4 cases received transluminal endoscopic debridement, 21 cases received laparoscopic debridement, and 709 cases received open laparotic debridement.Three hundred and sixty-five cases were admitted to our institute during January 2005 to December 2010, and the other 391 cases were admitted to our institute from January 2011 to December 2018. Of the first period, all debridement were performed with open laparotic procedures. Of the second period, debridement were performed with open laparotic procedures and minimal invasive procedures. The average times of surgical invasion, morbidity of principal local complications and mortality of the two periods were 1.27 and 1.34,28.22%(103/365) and 29.92%(117/346), and 6.03%(23/365) and 6.91%(27/346), respectively. Conclusions Minimal invasive procedures can be considered for debridement in patients with necrotizing pancreatitis in some selected conditions.The involvements of minimal invasive procedures in treatment of necrotizing pancreatitis don′t decrease the morbidity of principal local complications and mortality in recent years. Rational surgical procedures and appropriate surgical timing are the keys to improve the efficacy of necrotizing pancreatitis.

Objective: To investigate the clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy (MARPN) for infected pancreatic necrosis (IPN). Methods: The retrospective cohort study was conducted. The clinical data of 61 patients with IPN who were admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 2014 and December 2017 were collected. There were 39 males and 22 females, aged 36-67 years, with a median age of 49 years. Of 61 patients, 40 undergoing open surgery were allocated into open group, and 21 undergoing MARPN were allocated into MARPN group. All the patients underwent surgical treatments after standard non-surgical treatments according to the Guidelines for the diagnosis and treatment of severe acute pancreatitis (2014 edition). Observation indicators: (1) intraoperative and postoperative situations; (2) follow-up. Follow-up using telephone interview or outpatient examination was performed to detect weight loss, pathoglycemia, steatorrhea, intestinal obstruction, and pancreatic portal hypertension for one year after surgery up to December 2017. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Count data were represented as absolute numbers or percentages, and comparison between groups was done using the chi-square test. Results: (1) Intraoperative and postoperative situations: operation time, time to out-of-bed activity, time to initial food intake, cases with reoperation, cases with postoperative multiple organ dysfunction syndrome (MODS), incidence rate of postoperative complications, mortality, time to drainage-tube removal, duration of hospital stay, and hospital expenses were (77±20)minutes, (13.0±3.6)days, (9.0±2.7)days, 8, 9, 45.0%(18/40), 7.5%(3/40), (37.0±6.3)days, (49±8)days, (84 321±8 872)yuan in the open group, and (59±20)minutes, (2.7±0.9)days, (1.9±0.4)days, 6, 2, 19.0%(4/21), 0, (21.0±2.7)days, (39±6)days, (58 594±3 576)yuan in the MARPN group, respectively, showing no significant difference in the cases with reoperation (χ²=0.69, P>0.05) but significant differences in the other indices between the two groups (t=4.24, 9.61, 15.34, χ²=23.76, 4.02, 36.03, t=11.07, 5.93, 8.43, P<0.05). There were 18 patients with postoperative complications in the open group, including 2 with digestive hemorrhage, 3 with abdominal hemorrhage, 9 with pancreatic leakage, and 4 with intestinal leakage. There were 4 patients with postoperative complications in the MARPN group, including 3 with pancreatic leakage, and 1 with intestinal leakage. Patients with complications were treated by endoscopy, interventional therapy, placement of jejunal nutrition tube, and ileum stoma. Three patients in the open group died, and all the patients in the MARPN group were cured. (2) Follow-up: 47 of 61 patients were followed up for one year, including 31 in the open group and 16 in the MARPN group. During the follow-up, weight loss, pathoglycemia, steatorrhea, intestinal obstruction, and pancreatic portal hypertension were detected in 4, 11, 5, 4, 5 patients of the open group and in 2, 6, 2, 0, 3 patients of the MARPN group, showing no statistically significant difference between the two groups (χ²=0.18, 0.02, 0.01, 0.03, 0.90, P>0.05). Conclusion MARPN for IPN is safe and reliable, with certain efficacy, which can effectively reduce incidence of postoperative complication, motality and shorten hospital stay.

Objective To investigate the changes of surgical invitations on necrotizing pancreatitis in recent 14 years by reviewing single center data.Methods One thousand and eighty patients with necrotizing pancreatitis who received surgical invitation were involved in the study.All the patients were treated at Department of Pancreatic Surgery,Union Hospital,Tongji Medical College,Huazhong University of Science and Technology from January 2005 to December 2018. Six hundred and seventy?eight were males and 402 were females. The median (range) age of the study patients was 45 (20-76) years.The etiology of the disease was related to cholelithiasis in 335 cases(31.02%), hyperlipemia in 302 cases(27.96%), alcohol in 226 cases(20.93%), endoscopic retrograde cholangiopancreatography in 28 cases(2.59%), pregnancy in 50 cases(4.63%), idiopathic factors in 72 cases(6.67%) and other causes in 67 cases(6.20%). The patients were divided into two groups according to the time of admission. Group 1 included 1 475 patients that admitted from January 2005 to December 2010, and group 2 included 1 539 patients that admitted from January 2011 to December 2018. The surgical interventions, morbidity and mortality of the two group were compared, and χ2 test was used for the statistical test. Results Two hundred and sixty?six among the 1 080 cases were treated with drainage procedures because of the pseudocyst.One hundred and seventy?five drainage procedures were performed between January 2005 and December 2018, which account for 11.87%(175/1 475) of all patients of necrotizing pancreatitis; 91 drainage procedures were performed between January 2011 and December 2018,which account for 5.91%(91/1 539) of all patients of necrotizing pancreatitis. Eight hundred and fourteen cases received surgical intervention for infection of necrotizing tissues. Of these cases, 410 cases received percutaneous catheter drainage(PCD) of retroperitoneal fluid or residual infection. Debridement of necrotic tissues was performed on 756 cases. Of these cases, 32 cases received minimal invasive retroperitoneal debridement with/without denotes video assistant,4 cases received transluminal endoscopic debridement, 21 cases received laparoscopic debridement, and 709 cases received open laparotic debridement.Three hundred and sixty?five cases were admitted to our institute during January 2005 to December 2010, and the other 391 cases were admitted to our institute from January 2011 to December 2018. Of the first period, all debridement were performed with open laparotic procedures. Of the second period,debridement were performed with open laparotic procedures and minimal invasive procedures. The average times of surgical invasion, morbidity of principal local complications and mortality of the two periods were 1.27 and 1.34,28.22%(103/365) and 29.92%(117/346),and 6.03%(23/365) and 6.91%(27/346), respectively. Conclusions Minimal invasive procedures can be considered for debridement in patients with necrotizing pancreatitis in some selected conditions.The involvements of minimal invasive procedures in treatment of necrotizing pancreatitis don′t decrease the morbidity of principal local complications and mortality in recent years. Rational surgical procedures and appropriate surgical timing are the keys to improve the efficacy of necrotizing pancreatitis.

Objective To investigate the changes of surgical invitations on necrotizing pancreatitis in recent 14 years by reviewing single center data.Methods One thousand and eighty patients with necrotizing pancreatitis who received surgical invitation were involved in the study.All the patients were treated at Department of Pancreatic Surgery,Union Hospital,Tongji Medical College,Huazhong University of Science and Technology from January 2005 to December 2018. Six hundred and seventy?eight were males and 402 were females. The median (range) age of the study patients was 45 (20-76) years.The etiology of the disease was related to cholelithiasis in 335 cases(31.02%), hyperlipemia in 302 cases(27.96%), alcohol in 226 cases(20.93%), endoscopic retrograde cholangiopancreatography in 28 cases(2.59%), pregnancy in 50 cases(4.63%), idiopathic factors in 72 cases(6.67%) and other causes in 67 cases(6.20%). The patients were divided into two groups according to the time of admission. Group 1 included 1 475 patients that admitted from January 2005 to December 2010, and group 2 included 1 539 patients that admitted from January 2011 to December 2018. The surgical interventions, morbidity and mortality of the two group were compared, and χ2 test was used for the statistical test. Results Two hundred and sixty?six among the 1 080 cases were treated with drainage procedures because of the pseudocyst.One hundred and seventy?five drainage procedures were performed between January 2005 and December 2018, which account for 11.87%(175/1 475) of all patients of necrotizing pancreatitis; 91 drainage procedures were performed between January 2011 and December 2018,which account for 5.91%(91/1 539) of all patients of necrotizing pancreatitis. Eight hundred and fourteen cases received surgical intervention for infection of necrotizing tissues. Of these cases, 410 cases received percutaneous catheter drainage(PCD) of retroperitoneal fluid or residual infection. Debridement of necrotic tissues was performed on 756 cases. Of these cases, 32 cases received minimal invasive retroperitoneal debridement with/without denotes video assistant,4 cases received transluminal endoscopic debridement, 21 cases received laparoscopic debridement, and 709 cases received open laparotic debridement.Three hundred and sixty?five cases were admitted to our institute during January 2005 to December 2010, and the other 391 cases were admitted to our institute from January 2011 to December 2018. Of the first period, all debridement were performed with open laparotic procedures. Of the second period,debridement were performed with open laparotic procedures and minimal invasive procedures. The average times of surgical invasion, morbidity of principal local complications and mortality of the two periods were 1.27 and 1.34,28.22%(103/365) and 29.92%(117/346),and 6.03%(23/365) and 6.91%(27/346), respectively. Conclusions Minimal invasive procedures can be considered for debridement in patients with necrotizing pancreatitis in some selected conditions.The involvements of minimal invasive procedures in treatment of necrotizing pancreatitis don′t decrease the morbidity of principal local complications and mortality in recent years. Rational surgical procedures and appropriate surgical timing are the keys to improve the efficacy of necrotizing pancreatitis.

Pancreatic cancer is one of the digestive malignant tumors with the worst prognosis and has an overall 5 -year survival rate as low as 5%.Even though radical resection is performed,the 5 -year survival rate is only about 20%.Recurrence and metastasis are the most important influencing factors for the postoperative survival of patients with pancreatic cancer.Lymph node metastasis is an important feature of pancreatic cancer,and the extent of lymph node dissection has always been a hot topic in radical surgery for pancreatic cancer.This arti-cle summarizes the history and current status of the extent of lymph node dissection in pancreatic cancer and points out that standardized lymph node dissection is a key factor for improving patients′prognosis after pancreatic cancer surgery.

OBJECTIVETo investigate the indication, timing and methods of surgery for acute necrotizing pancreatitis.

METHODSThere were 5 538 patients with acute pancreatitis (AP) were treated in the Union Hospital, Tongji Medical College from January 2005 to December 2014. Of all AP cases, 2 415 patients with acute necrotizing pancreatitis proved by computed tomography, and 732 patients underwent surgical treatment. Among 732 patients with surgical treatment, 439 (60.0%) were males and two hundreds and ninety-three (40.0%) were females. The median age was 45 years, ranging 20-76 years. Two hundreds and eighty-nine cases were treated with minimally invasive debridement and drainage and 684 cases were treated with open debridement.

RESULTSThe cure rate of minimally invasive operation was 16.6% (48/289). The rest of the 241 patients were treated furtherly with open necrosectomy. Among 684 patients with open surgery, 523 patients (76.5%) were infected, and the median time from the onset of symptom to first open operation was 46 d (range 19-205 d). There were 115 patients need to surgery again because of necrotic tissue residual and the reoperation rate was 16.81% (115/684), 684 patients were performed open surgery on average 1.26 times per person. The main postoperative complications were intra-abdominal hemorrhage (37 cases), upper digestive tract fistula (34 cases), colonic fistula (12 cases), gastrointestinal obstruction (29 cases) and pancreatic fistula (83 cases). The overall incidence of complications were 28.5% (195/684). Forty-nine cases died after surgery and the mortality rate was 6.7% (49/732).

CONCLUSIONRational surgical indications and timing of surgical intervention are the key to improve the efficacy of necrotizing pancreatitis, open debridement is still an effective method for necrotizing pancreatitis.

Adult ; Aged ; Debridement ; Drainage ; Female ; Humans ; Male ; Middle Aged ; Minimally Invasive Surgical Procedures ; Pancreatitis, Acute Necrotizing ; surgery ; Postoperative Complications ; Reoperation ; Tomography, X-Ray Computed ; Treatment Outcome ; Young Adult

Severe acute pancreatitis (SAP) is hard to treat for the abrupt onset, critical condition and complicated pathophysiology. Historically, the treatment strategy of SAP hovered between surgical intervention and conservative treatment. At the turn of the 20(th) century, SAP was reported to be cured by surgical intervention in a series cases, which lead to the dominance of surgical intervention in SAP treatment. Subsequently, SAP was documented to respond to nonoperative therapy. A wave of conservatism emerged, and surgical intervention for SAP was rarely practiced for the next 3 decades. However, surgeons refined the indications and considered new approaches for surgical treatment in 1960s because of the poor outcomes of conservation, and surgical interventions was mainly performed at early stage of SAP. However, a series of prospective studies showed that conservative treatment of patients with sterile pancreatic necrosis is superior to surgical intervention, and that delayed intervention provide improved outcomes in 1990s, which changed the treatment concept of SAP again. The modern treatment concept formed during the progression: organ supportive care dominates in the early stage of the disease, and surgical intervention should be performed at late stage with proper indications. Despite the advances in treatment, the morbidity of SAP is still 5%-20%, which suggests the pancreatic surgeons' exploration in the future.
Disease Progression ; History, 20th Century ; Humans ; Pancreatectomy ; history ; Pancreatitis ; surgery