Evolving trends in interventions and outcomes for acute biliary pancreatitis during pregnancy: A two-decade analysis

BACKGROUND/OBJECTIVES

Cholelithiasis is the most common cause of acute pancreatitis in pregnancy. We analyzed trends in acute biliary pancreatitis (ABP) among pregnant women over the past two decades to evaluate changes in outcomes, including the incidence of severe acute pancreatitis, mortality rates, and hospital length of stay.

METHODS

Using the National Inpatient Sample, we identified adult women of childbearing age (age 18-50 years) with hospitalization for ABP from 2002 to 2020. Trends were analyzed using Cochran-Armitage and F-tests. Multivariable binary logistic regression was used to evaluate the outcome of severe acute pancreatitis (SAP).

RESULTS

45,064 pregnant and 212,009 non-pregnant women were hospitalized for ABP (2002-2020), with a significant increase in ABP during pregnancy (14.1 %→17.8 %; p < 0.001). Trend analyses in the pregnant cohort revealed increasing age (mean 27  →  28.1 years; p < 0.001), Class-III obesity (0.7 %→7.8 %; p < 0.001), comorbidities (Elixhauser index ≥3) (2.9 %→11.2 %; p < 0.001), and SAP (2.2 %→5.0 %; p < 0.001). Mortality remained very low (<0.01 %). Performance of ERCP (22.2 %→26.5 %; p < 0.001) and cholecystectomy (41.0 %→54.1 %; p < 0.001) increased while duration of hospitalization decreased (Mean 4.9  →  3.6 days; p < 0.001). Multivariable analysis revealed that the development of SAP was associated with Black race (OR 1.70, 95 % CI: 1.10-2.63) and comorbidities (OR 5.10, 95 % CI 3.64-7.14).

CONCLUSIONS

Pregnant women represent a significant portion of hospitalized ABP cases, paralleling increases in age, comorbidities, and obesity rates. Racial disparities are linked to higher odds of SAP, though comorbidities have a dominant effect. There has been an increase in guideline-recommended procedures (ERCP and cholecystectomy); however, further research is needed to address the implementation gap, considering the increased complexity of pregnant women with ABP.

Construction and validation of a nomogram for predicting survival in diabetic patients with severe acute pancreatitis: A retrospective study from a tertiary center

BACKGROUND

There is currently a lack of nomograms specifically designed for predicting the risk of death in diabetic patients with severe acute pancreatitis (SAP). The objective of this study was to develop a nomogram tailored to diabetic patients with SAP to predict overall survival.

METHODS

Diabetic patients diagnosed with SAP between January 1, 2018 and December 31, 2023 were included in the study. Risk factors were identified through least absolute shrinkage and selection operator regression analysis. Subsequently, a novel nomogram model was developed through multivariable logistic regression analysis. The predictive performance of the nomogram was evaluated using metrics such as the receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA).

RESULTS

A total of 206 patients were included in the analysis, with 171 in the survival group and 35 in the deceased group. Multivariate logistic regression indicated that age, platelet, total bilirubin, and potassium were independent prognostic factors for the survival of diabetic patients with SAP. The nomogram demonstrated a performance comparable to sequential organ failure assessment ( P = 0.570). Additionally, the calibration curve showed satisfactory predictive accuracy, and the DCA highlighted the clinical application value of the nomogram.

CONCLUSION

We have identified key demographic and laboratory parameters that are associated with the survival of diabetic patients with SAP. These parameters have been utilized to create a precise and user-friendly nomogram, which could be an effective and valuable clinical tool for clinicians.

The role of MRCP for preventing pancreatic fluid collection recurrence after EUS-guided drainage of walled-off necrosis

BACKGROUND AND AIMS

Pancreatic fluid collections (PFCs) may recur after initial successful endoscopic drainage of walled-off necrosis (WON), most commonly due to disconnected pancreatic duct syndrome (DPDS). The primary aim of this study was to assess the role of MRCP for identifying DPDS to guide appropriate management and prevent PFC recurrence.

METHODS

Patients with WON undergoing lumen-apposing metal stent drainage of a PFC were retrospectively identified and categorized as those with MRCP versus those without MRCP before removal of transmural stents. Data on patient demographic characteristics, procedural details, cross-sectional imaging, and recurrence rates were collected through chart review.

RESULTS

A total of 121 patients with WON were identified, of whom 44 (36.4%) had an MRCP before transmural stent removal. In patients without MRCP, 13 (16.8%) of 77 had PFC recurrence versus 0 of 44 (0%; P = .003) in those with MRCP. MRCP identified DPDS in 12 (27.2%) patients, all of whom were managed with indefinite drainage with double-pigtail plastic stents without recurrence. In the group without MRCP, PFCs recurred at a median interval of 284 days (interquartile range, 182-618 days) after transmural stent removal. Among the 13 patients with PFC recurrence, 11 (85%) had undiagnosed DPDS detected on subsequent imaging, of whom 9 were subsequently managed with indefinite double-pigtail plastic stents, with no further PFC recurrence.

CONCLUSIONS

Patients with WON who underwent MRCP before transmural stent removal had a lower rate of PFC recurrence largely due to the identification of DPDS with appropriate endoscopic management.

Vascular injuries and complications in anterior lumbar interbody fusion: an up-to-date review

Vascular injuries during anterior lumbar interbody fusion (ALIF) are reported in the existing literature with an incidence rate ranging from 1% to 24%, predominantly venous lacerations owing to branch vessel avulsions during mobilization and retraction. Arterial injuries, although less frequent, occur at an incidence of 0.45% to 1.5% and are mainly characterized by thromboses; aortic lacerations remain exceptionally rare. L4-L5 and L5-S1 are the two levels associated with the majority of vascular complications. Preoperative 3D CT angiography is paramount and a gold standard, as it illustrates the anatomic variations of the iliolumbar vein, the aorta, and the vena cava bifurcation, providing the surgeon with valuable information regarding operative trajectories. Regarding preventive measures, venous laceration, the most common vascular injury, occurs less frequently when employing nonthreaded interbody grafts such as iliac crest autograft or femoral ring allograft. Also, left iliac artery thrombosis can be decreased intraoperatively by intermittent release of retraction. Managing vascular complications includes compression for bleeding control, Trendeleburg positioning of the patient and venorrhaphy, and the employment of topical clot-forming enhancement and/or hemostatic agents. Although postoperative lower limb duplex ultrasonography can be an effective tool, magnetic resonance venography (MRV) and intravenous catheterization (IVC) remain the gold standards for diagnosing postoperative pelvic vein thrombosis in cases of iliac vein repair after anterior spine surgery. This paper aimed to highlight the incidence of major vascular injury during ALIF surgery, describe predisposing risk factors, and discuss management techniques while highlighting the requirement for more sensitive and factor-specific studies to attain a more profound understanding of the mechanism of vasculature complications during ALIF procedures.

Perioperative outcomes of robotic vs laparoscopic pancreatoduodenectomy: a meta-analysis and trial sequential analysis

BACKGROUND

Minimally invasive pancreatoduodenectomy has gained widespread acceptance among hepatopancreatobiliary surgeons due to its demonstrated advantages in perioperative outcomes compared to the conventional open approach. This meta-analysis, along with trial sequential analysis, aimed to compare the outcomes of robotic pancreatoduodenectomy and laparoscopic pancreatoduodenectomy based on the current available evidence.

METHODS

A systematic search of PubMed, Cochrane, Scopus, and Web of Science was conducted from inception to July 2024. We assessed intraoperative and postoperative outcomes, including open conversion rates, readmission, reoperation, and mortality. Additional factors, such as blood loss and the number of lymph nodes resected, were also evaluated. Quality assessment was performed using Cochrane's risk of bias tools. Subgroup analysis was conducted based on propensity score matching status, and trial sequential analysis was applied to statistically significant results on first analysis.

RESULTS

We meta-analyzed seventeen studies, with a total of 5,483 patients. The meta-analysis reported lower rates of open conversion (OR 0.40; 95% CI 0.26-0.61; p = < 0.001) and a higher number of lymph nodes resected (MD 3.5; 95% CI 1.45-5.55; p = 0.0008) in the RPD group. These results remained consistent after subgroup analysis. Trial sequential analysis confirmed true positive results, indicating that further studies are unnecessary to detect a significant difference. However, other perioperative outcomes did not show statistical significance and failed to reach the required information size for definitive conclusions.

CONCLUSION

This meta-analysis of non-randomized cohorts found lower rates of open conversion and a higher number of lymph nodes resected in patients undergoing robotic pancreatoduodenectomy. However, the initial analysis did not reveal statistically significant differences in transfusion rates, multivisceral and vascular resections, hemorrhage, delayed gastric emptying, mortality, or readmission rates. Future studies should focus on randomized designs, target more specific populations, and include long-term outcomes for a more comprehensive analysis.

A Case Report on Protease Serine 1 (PRSS1)-Related Acute Pancreatitis

Acute pancreatitis (AP) is a multifactorial disease. Genetic predisposition as the etiology of AP is rare. We report the case of a 29-year-old male patient who presented with symptoms suggestive of AP. A complete workup, including genetic analysis, revealed the presence of both protease serine 1 (PRSS1) and UDP Glucuronosyltransferase family 1 member A1 (UGT1A1) mutations. Both PRSS1 and UGT1A1 mutations can cause AP by different mechanisms. This case has been reported because of the novelty of the two different genetic mutations in the same individual that could independently increase pancreatitis risk. The possible synergistic effect has not been reported previously. Understanding this interaction emphasizes the importance of genetic testing in AP.

National survey on data governance and digital surgery: Challenges and opportunities for surgeons in the era of artificial intelligence

INTRODUCTION

This study evaluates the knowledge of Spanish surgeons regarding data governance and Digital Surgery, their usage, errors, and training deficiencies, as well as differences in knowledge between those who perform robotic surgery and those who do not.

METHODS

A descriptive study was conducted using a closed survey promoted by the Minimally Invasive Surgery and Technological Innovation Section of the Spanish Association of Surgeons, directed at its members between February and March 2024.

RESULTS

Out of 1086 surgeons contacted, 396 responded (36.46%). While 98.3% use electronic medical records, 45.4% lack organized data recording systems. Although 55.9% have access to robotic technology, 70.6% do not use it directly. Surgeons who perform robotic surgery show a higher general knowledge of Digital Surgery terms (7.2 vs 6.619; P = .215) and specifically of "Artificial Intelligence" (57.14% compared to less than 25% for other terms), although these differences are not significant. However, there are significant differences in interest in digital technology between those who perform robotic surgery and those who do not (P = .023). Additionally, surgeons who support training in digital technology during residency are nearly twice as likely to research Digital Surgery.

CONCLUSION

Surgeons are crucial for the digital transformation in surgery, but many are poorly prepared and insufficiently involved. Those who practice robotic surgery have more knowledge and interest in digital technology, highlighting the need for improved training and governance frameworks to better integrate surgeons into the digital era.

Role of Minimally Invasive Reoperation for Postoperatively Diagnosed T2 Gallbladder Cancer: Multicenter Retrospective Cohort Study

BACKGROUND

Although T2 gallbladder cancer (GBC) incidentally diagnosed after cholecystectomy requires additional resection, the surgical approaches are technically difficult due to inflammatory adhesion or fibrosis around the hepatoduodenal ligament and gallbladder bed. In this study, we sought to compare the surgical and oncologic outcomes of open and minimally invasive reoperation for postoperatively diagnosed T2 GBC.

STUDY DESIGN

Patients who underwent open (110) and laparoscopic (38) reoperation for T2 GBC between November 2004 and October 2022 at 5 tertiary referral centers were included in this multicenter retrospective cohort study. The short- and long-term outcomes were compared between the 2 groups.

RESULTS

There were no differences in clinicopathologic characteristics between the open and laparoscopic groups. Liver resection was more frequent in the open group (101 [91.8%] vs 21 [55.3%], p < 0.001). Compared with open operation, laparoscopic reoperation was associated with shorter postoperative hospital stay (9.0 [8.0 to 10.0] vs 6.0 [3.8 to 8.3] days, p < 0.001) and a lower postoperative complication rate (24 [21.8%] vs 1 [2.6%], p = 0.013). Among patients who underwent liver resection, the postoperative hospital stay was shorter in the laparoscopic group (9.0 [8.0 to 10.0] vs 6.0 [4.0 to 9.0] days, p = 0.004). The 5-year disease-free survival (66.7% vs 76.1%, p = 0.749) and overall survival (75.2% vs 73.7%, p = 0.789) rates were not significantly different between the 2 groups.

CONCLUSIONS

The results indicate that laparoscopic reoperation for postoperatively diagnosed T2 GBC has favorable postoperative outcomes and similar oncologic safety compared with open operation.

Organ Failure and Prediction of Severity in Acute Pancreatitis

Organ failure (OF) is a sinister development in the clinical course of acute pancreatitis, and its prediction is crucial for triaging the patient. Persistent systemic inflammatory response syndrome and raised interleukin-6 levels have a good predictive accuracy. Pathophysiology involves the release of damage-associated molecular patterns as a consequence of pancreatic injury, recruitment of inflammatory cells, and the release of proinflammatory cytokines and chemokines causing cytokine storm. Respiratory system is the most common and earliest to fail. Although a few therapeutic options are in the pipeline, renewed efforts are required to develop targeted therapies to mitigate systemic inflammation and OF.

Bodyweight-Adjusted Nonsteroidal Anti-inflammatory Drugs Dose in the Prevention of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis

OBJECTIVES

Although rectal nonsteroidal anti-inflammatory drugs (NSAIDs) reduce the incidence of postendoscopic retrograde cholangiopancreatography pancreatitis (PEP), their optimal dosage is unknown. Given possible interindividual variability in the pharmacodynamics of NSAIDs, we hypothesized that the dose required to achieve adequate PEP prophylaxis varies with body weight.

MATERIALS AND METHODS

We conducted an analysis using single-center, prospective, observational cohort study data. The primary outcome was PEP incidence by NSAID dosage per body weight (mg/kg). Patients meeting the inclusion criteria were classified into 3 groups.

RESULTS

We included 891 patients, with 400, 454, and 37 patients in the control group with no NSAID therapy, the NSAID <1.0 mg/kg group, and the NSAID ≥1.0 mg/kg group, respectively. In the adjusted cohort, the odds ratio of PEP was 0.18 (95% confidence interval: 0.041-0.79; P = 0.023) for NSAID ≥1.0 mg/kg and 1.3 (95% confidence interval: 0.76-2.3; P = 0.31) for NSAID <1.0 mg/kg compared to the control group without NSAID.

CONCLUSIONS

PEP was not prevented by NSAID dosages below 1.0 mg/kg body weight whereas a dosage above 1.0 mg/kg body weight had a significant prophylactic effect. An NSAID dosage adjusted to body weight may be necessary to achieve an adequate prophylactic effect against PEP.

Introduction to Artificial Intelligence for General Surgeons: A Narrative Review

Artificial intelligence (AI) has rapidly progressed in the last decade and will inevitably become incorporated into trauma and surgical systems. In such settings, surgeons often need to make high-stakes, time-sensitive, and complex decisions with limited or uncertain information. AI has great potential to augment the pre-operative, intra-operative, and post-operative phases of trauma care. Despite the expeditious advancement of AI, many surgeons lack a foundational understanding of AI terminology, its processes, and potential applications in clinical practice. This narrative review aims to educate general surgeons about the basics of AI, highlight its applications in thoraco-abdominal trauma, and discuss the implications of incorporating its use into the Australian health care system. This review found that studies of AI in trauma care have predominantly focused on machine learning and deep learning applied to diagnostics, risk prediction, and decision-making. Other subfields of AI include natural language processing and computer vision. While AI tools have many potential applications in trauma care, current clinical use is limited. Future prospective, locally validated research is required prior to incorporating AI into clinical practice.

Endoscopic Step-Up Approach in Management of Necrotizing Pancreatitis

The endoscopic step-up approach in the management of necrotizing pancreatitis involves sequential steps of intervention at different time points in the clinical course of the disease. EUS -guided drainage of walled-off necrosis is the first step of the endoscopic step-up approach. Lumen-apposing metal stents are preferred over plastic stents for safe and effective drainage because of their wide caliber. Successive steps in the endoscopic step-up approach include direct endoscopic necrosectomy and/or irrigation using naso-cystic tube in symptomatic patients, primarily based on necrotic debris characteristics. Minimally invasive percutaneous radiological and/or surgical drainage are considered when endoscopic drainage is not feasible or successful.

Pancreatic necrosis: a scoping review

Acute pancreatitis (AP) is a commonly encountered GI diagnosis, accounting for 275,000 hospital admissions annually in the United States alone. Pancreatic necrosis (PN) is the most common complication of AP, and the development of PN is associated with significant morbidity and increased mortality. This expert review evaluates the evidence-based management of symptomatic PN from the era of maximal open pancreatic necrosectomy in the late 1990s though the modern paradigm of minimally invasive and endoscopic interventions. The authors present the retrospective and controlled data behind the "step-up approach" to PN treatment and discuss the application of current society guidance. Evidence based management of PN is characterized by early supportive care, and treatment by minimally invasive intervention when a patient is critically ill or persistently symptomatic. Appropriate choices when intervention is required include percutaneous drainage, minimally invasive surgery, and/or endoscopic treatment. The transition from open maximal necrosectomy to minimally invasive intervention has resulted in improved outcomes for patients, including gains in mortality, significant morbidity, and cost. The ideal precision management strategy for an individual patient remains an area of increasing understanding.

Surgical Step-Up Approach in Management of Necrotizing Pancreatitis

Necrotizing pancreatitis often demands intervention; contemporary management is directed by the step-up approach. Timing of intervention and specific approach is best directed by a multi-disciplinary team including advanced endosocpists, interventional radiologists, and surgeons with interest and experience managing this complex problem. The intervention is often a combination of percutaneous drainage, transluminal endoscopic approaches, and surgical debridement (minimally invasive or open). Goals of treatment are to evacuate solid infected necrosis, gain enteral access when needed, and to prevent recurrence-cholecystectomy in the setting of biliary pancreatitis. Experienced clinical judgment leads to optimal patient outcomes.

Pancreatitis in children: practical management from the BSPGHAN Pancreatitis Working Group

Pancreatitis, a condition characterised by inflammation of the pancreas, has multiple aetiologies. Improving clinical proficiency in prompt diagnosis and effective management leads to better outcomes for children with acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Establishing consensus guidance via the British Society of Paediatric Gastroenterology Hepatology and Nutrition Pancreatitis Working Group has ensured further focus on these patients who are often cared for in a multidisciplinary framework and may prompt future research in this area. Initial assessment includes serum amylase/lipase, triglyceride levels, full blood count, C reactive protein, renal and liver function profile, glucose, calcium and capillary blood gas. Fasted transabdominal ultrasound for all children and young people with suspected pancreatitis is recommended to identify pancreatic parenchyma and pancreatobiliary ductal changes, and complications. For fluid resuscitation, use crystalloids or Ringer’s lactate: initial bolus of 10 to 20 mL/kg, 1.5–2 times maintenance volume, with hourly monitoring of urine output over the initial 24–48 hours. Initiate oral intake within the first 24 hours after fluid resuscitation; fat restriction is not recommended. For suspected autoimmune pancreatitis, workup includes immunoglobulin levels (IgG, IgM, IgA, IgG subclasses), complement components and autoantibody profile to confirm diagnosis. Significant interventional management for pancreatitis and related complications is performed via endoscopic retrograde cholangiopancreatography or endoscopic ultrasound; referral to a specialised paediatric hepatobiliary surgical team is highly recommended. Close collaboration with a specialist centre can improve diagnostic and management pathways and outcomes for children.

Diffusion weighted MRI and neutrophil lymphocyte ratio non-invasively predict infection in pancreatic necrosis: a pilot study

BACKGROUND

Infected pancreatic necrosis (IPN) is a major determinant of mortality in acute pancreatitis (AP). Non-invasive diagnosis of IPN could guide the intervention in AP. We aimed to investigate the role of non-invasive methods like diffusion weighted magnetic resonance imaging (DW-MRI) and clinico-laboratory parameters as predictors of IPN.

METHODS

Prospective evaluation for predictors of IPN by diffusion restriction (DR) on DW-MRI and clinico-laboratory parameters was performed.

RESULTS

Out of 39 patients included, 31 were analysed after exclusion. Twenty-six (83.8%) patients had moderately severe AP, and the rest had severe disease. They were categorized into Group A: patients with documented infection after intervention (n = 17) and Group B: successfully managed without intervention or negative culture after intervention (n = 14). On univariate analysis, Group A had significantly more incidence of fever (P = 0.020), persistent unwellness (P = 0.003), elevated neutrophil count (P = 0.007), lymphocyte count (P = 0.007), neutrophil lymphocyte ratio (NLR) (P = 0.028), DR on DW-MRI (P = 0.001) and low apparent diffusion coefficient (ADC) (P = 0.086). Multivariate analysis revealed DR on DW-MRI (P = 0.004) and NLR (P = 0.035) as significant predictors of IPN, among other factors. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DW-MRI were 94.1%, 78.6%, 91.66%, and 84.21%, respectively. The area under curve of NLR on the ROC plot was 0.85 and the best cutoff was >3.5, with sensitivity, specificity, PPV, and NPV of 70.6%, 78.6%, 80%, and 68.7% respectively.

CONCLUSION

DW-MRI and NLR are promising non-invasive tools for accurate prediction of IPN and hence can guide the need for intervention in acute pancreatitis.

Safety and efficacy of lumen-apposing metal stents for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a systematic review and meta-analysis

Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) has variable outcomes according to the type of lumen-apposing metal stent (LAMS) used. We aimed to perform a systematic review and meta-analysis of the available data.Online databases, including EMBASE, PubMed, and SCOPUS, were searched from inception to 30 January 2024. The outcomes of interest were technical success, clinical success, adverse events (AEs), and the need for endoscopic necrosectomy. Pooled estimates stratified by the type of stent (Axios, Nagi, or Spaxus), severity of bleeding, and type of PFC were calculated using a random-effects model. Heterogeneity was assessed by I 2 values.37 studies were included in the final analysis. The pooled outcomes (95%CIs) for PFC drainage using the Axios, Nagi, and Spaxus stents, respectively, were: technical success 97.7% (96.4%-98.8%), 96.9% (94.6%-98.5%), 98.2% (94.4%-99.9%); clinical success 90.9% (88.7%-92.8%), 88.5% (79.9%-95.0%), 93.5% (91.0%-95.6%); total AEs 20.4% (16.6%-24.6%), 17.1% (8.3%-28.3%), 7.6% (3.6%-13.0); migration 4.2% (2.9%-5.7%), 7.8% (4.1%-12.4%), 0.9% (0.1%-2.8%); overall bleeding 7.0% (4.9%-9.5%), 4.4% (2.2%-7.4%), 1.8% (0.8%-3.3%); and endoscopic necrosectomy 54.5% (38.9%-69.7%), 16.0% (11.4%-21.3%), 19.9% (6.6%-38.1%). In terms of severity, moderate-severe bleeding was most common with all three stents. AEs were higher in patients with walled-off necrosis compared with pseudocysts. Substantial-to-considerable heterogeneity (I 2 >60%) was present for total AEs for all of the stents.Our study shows good technical and clinical success rates with all three LAMSs for EUS-guided PFC drainage. Total AEs and bleeding were highest with the Axios stent and lowest with the Spaxus. Stent migration was highest with the Nagi stent and lowest with the Spaxus.

Percutaneous cystogastrostomy for treatment of pancreatic collections

OBJECTIVE

Acute pancreatitis (AP) is an inflammatory condition associated with a potential torpid evolution comprising multiple organ failure, pancreatic necrosis, infected collections and high mortality. Current management tends use the step-up approach, with endoscopic collection drainage, followed by percutaneous drainage by an interventional radiologist and video-assisted necrosectomy. We present our experience with a new percutaneous technique of establishing an anastomosis of the pancreatic collection with the closest loop, stomach, duodenum or jejunum that uses balloon dilation and drainage in cases of infection.

MATERIAL AND METHODS

Between 2009 and 2023 we have applied this technique in 30 patients, aged between 32 and 82 years (mean=67 years), 14 with pseudocysts (infected in six cases) and 16 with encapsulated necrosis (all infected). We use dilation balloons of different calibre, to establish the anastomosis between the digestive loop and the collection, as well as different drainages.

RESULTS

The intervention had a primary technical success of 93%. In two patients the cystogastrostomy had to be repeated due to initial technical failure; in both cases a good result was achieved. One patient had a severe postintervention haemorrhage (3%) that required embolisation. Length of follow-up has ranged from between three months and 10 years (mean=4 years), with no recurrence of the anastomosed collection or cutaneous fistula observed in any case.

CONCLUSION

Percutaneous cystogastrostomy is a technique that allows infected collections to be resolved and pancreatic fistulas to be avoided, with few complications, which can be resolved by interventional vascular radiologists.

Laparoscopic Reoperation for Postoperatively Diagnosed Gallbladder Cancer: Technical Options for Cystic Duct Management

BACKGROUND

Gallbladder cancer is a rare disease with poor prognosis, for which surgical resection is considered the only curative treatment.1 The widespread adoption of laparoscopic cholecystectomy for benign biliary diseases has led to an increased incidence of postoperatively diagnosed gallbladder cancer.2-5 Several studies have proposed that tumors exceeding stage T2 require additional resection.3,6,7 However, reoperation for postoperatively diagnosed gallbladder cancer is technically difficult due to inflammatory adhesion or fibrosis around the hepatoduodenal ligament and gallbladder bed.8,9 For such reasons, there are limited evidence regarding the safety and feasibility of laparoscopic reoperation and no clear indications for when to perform minimally invasive surgery.

METHODS

In this multimedia article, we present the laparoscopic reoperation techniques for postoperatively diagnosed gallbladder cancer. We focus specifically on various approaches to surgically manage the cystic duct stump, depending on the length of remnant stump, degree of surrounding fibrosis, and margin status.

RESULTS

We represent three cases with different approaches. In the first case, a patient with a long remnant stump is managed with clip ligation and resection of the stump. Second, a patient with a short remnant stump and severe fibrosis is treated with stump excision and suture closure. Lastly, bile duct resection is performed for a patient with margin involvement during the initial operation.

CONCLUSIONS

Various technical options exist to approach the remnant cystic duct stump during laparoscopic reoperation for postoperatively diagnosed gallbladder cancer.

SAGES guidelines update to laparoscopy in the era of COVID-19

BACKGROUND

Patients requiring cholecystectomy or appendectomy may present with concomitant COVID infection in both the inpatient and outpatient scenarios. It is unclear whether these patients benefit more from operative or nonoperative management in the setting of active COVID infection. These guidelines seek to address urgent and elective clinical scenarios.

METHODS

A systematic review was conducted to address these questions. These results were then presented to an interdisciplinary panel that formulated recommendations based on the best available evidence or utilized expert opinion when the evidence base was lacking.

RESULTS

Conditional recommendations were made in favor of (1) either operative or nonoperative management of COVID-positive patients with appendicitis or cholecystitis and (2) delaying operations by more than six weeks in patients who test positive for COVID in the elective setting.

CONCLUSIONS

These recommendations should provide guidance regarding the management of surgical patients with concomitant COVID infection. This guideline also identifies important areas where future research should focus to strengthen the evidence base.

Metal stents versus plastic stents for drainage of pancreatic fluid collections: a systematic review and meta-analysis of randomized trials with trial sequential analysis

BACKGROUND AND AIMS

Pancreatic fluid collections (PFCs), including walled-off necrosis (WON), are significant complications of acute pancreatitis, and their management often involves drainage, although the optimal type of stent for this purpose remains uncertain. This meta-analysis aimed to compare metal versus plastic stents for endoscopic ultrasound (EUS)-guided drainage of PFCs.

METHODS

We searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs) comparing metal with plastic stents for drainage of PFCs. The odds ratio (OR) was used for binary outcomes and the mean difference (MD) for continuous outcomes with their respective 95% confidence interval (CI).

RESULTS

This study included eight RCTs and over 500 patients. Procedure duration was shorter in the metal stent arm compared with the plastic stent arm (MD - 10.63; 95% CI - 16.12 to - 5.15, p < 0.001). However, there was no statistically significant difference between metal and plastic stents in clinical success (OR 1.10; 95% CI 0.56 to 2.14), technical success (OR 1.53; 95% CI 0.23 to 10.0), overall mortality (OR 0.75; 95% CI 0.34 to 1.67), recurrence (OR 1.76; 95%CI 0.70 to 4.44), total number of interventions (MD 0.06; 95% CI - 0.52 to 0.64), need of necrosectomy (OR 1.27; 95% CI 0.77 to 2.11), length of hospitalization (MD - 0.41; 95% CI - 5.10 to 4.27), exocrine insufficiency (OR 1.37; 95% CI 0.50 to 3.71), endocrine insufficiency (OR 1.11; 95% CI 0.57 to 2.16), and adverse events (OR 0.74; 95% CI 0.39 to 1.41).

CONCLUSION

Metal stents for EUS-guided drainage of WON are associated with a shorter procedure duration. Besides that, it may not improve other clinically relevant outcomes in comparison with plastic stents.

Adjuvant non-opioid analgesics decrease in-hospital mortality in targeted patients with acute pancreatitis receiving opioids

OBJECTIVES

Opioid administration in acute pancreatitis (AP) exacerbates its severity, prompting concerns regarding the increased requirement for intensive care and its potential impact on patient survival. We aimed to elucidate the influence of analgesic patterns on mortality among patients with AP hospitalized in the ICU.

METHODS

We included 784 patients (198 receiving opioid monotherapy and 586 receiving opioid polytherapy) from the Medical Information Mart for Intensive Care database. The primary outcome was in-hospital mortality. Propensity score matching was used to account for baseline differences. We used Kaplan-Meier survival curves and multivariate regression models to indicate survival discrepancies and potential associations.

RESULTS

Polytherapy group exhibited prolonged hospital survival (79.8 vs. 57.3 days, P < 0.001); polytherapy was associated with decreasing in-hospital mortality adjusted for confounders (HR = 0.49, 95% CI: 0.26-0.92; P = 0.027). Stratification analysis indicated that patients receiving adjunctive acetaminophen had prolonged hospital survival (opioid vs. opioid + acetaminophen, P < 0.001; opioid vs. opioid + NSAIDs + acetaminophen, P = 0.026). Opioid polytherapy benefited patients with APACHE III scores >83 and those with mean oral morphine equivalent >60 mg/day (HR = 0.17, 95% CI: 0.1-0.3, P < 0.001 and HR = 0.32, 95% CI: 0.2-0.52, P < 0.001, respectively).

CONCLUSION

Our findings suggest that an opioid-based analgesic regimen offers a survival advantage for patients with AP, particularly those in critical condition or with concerns about opioid use. This approach provides a viable clinical strategy for pain management. Further randomized clinical trials are warranted to validate these results.

Targeted animal models for preclinical assessment of cellular and gene therapies in pancreatic and liver diseases: regulatory and practical insights

Cellular and gene therapy (CGT) products have emerged as a popular approach in regenerative medicine, showing promise in treating various pancreatic and liver diseases in numerous clinical trials. Before these therapies can be tested in human clinical trials, it is essential to evaluate their safety and efficacy in relevant animal models. Such preclinical testing is often required to obtain regulatory approval for investigational new drugs. However, there is a lack of detailed guidance on selecting appropriate animal models for CGT therapies targeting specific pancreatic and liver conditions, such as pancreatitis and chronic liver diseases. In this review, the gastrointestinal committee for the International Society for Cell and Gene Therapy provides a summary of current recommendations for animal species and disease model selection, as outlined by the US Food and Drug Administration, with references to EU EMA and Japan PMDA. We discuss a range of small and large animal models, as well as humanized models, that are suitable for preclinical testing of CGT products aimed at treating pancreatic and liver diseases. For each model, we cover the associated pathophysiology, commonly used metrics for assessing disease status, the pros and limitations of the models, and the relevance of these models to human conditions. We also summarize the use and application of humanized mouse and other animal models in evaluating the safety and efficacy of CGT products. This review aims to provide comprehensive guidance for selecting appropriate animal species and models to help bridge the gap between the preclinical research and clinical trials using CGT therapies for specific pancreatic and liver diseases.

Indications for and limitations of laparoscopic anatomical liver resection: assessment of postoperative complications stratified by complexity of liver resection

BACKGROUND

Although complex anatomical liver resections are more often being performed laparoscopically, the short-term outcomes following laparoscopic anatomical liver resection (LALR), its optimal indications, and limitations remain unclear. This study aimed to clarify the indications for and limitations of LALR by assessing the short-term outcomes.

METHODS

This retrospective study included 233 patients who underwent LALR. The complexity of LALR was categorized into three levels: Grade I (low), grade II (moderate), and grade III (high). Short-term outcomes were compared among these groups, and the risk factors for severe morbidity were identified.

RESULTS

The patients' backgrounds were similar across the three groups. Intraoperative blood loss, Pringle maneuver time, and postoperative hospital stay were comparable between grade I (n = 59) and grade II (n = 65) LALR but were greater for grade III (n = 109). The transfusion and conversion rates were similar among the three groups. The operative time increased with the rise in difficulty grade. The rate of severe morbidity was 3.4% in grade I, 6.2% in grade II, and 16.5% in grade III LALR (P = 0.012). Multivariable analysis identified three perioperative risk factors for severe morbidity: Operative time of ≥ 540 min (odds ratio [OR] = 4.762, P = 0.009), intraoperative blood loss of ≥ 350 mL (OR = 3.982, P = 0.024), and preoperative serum albumin of ≤ 3.8 g/dL (OR = 3.518, P = 0.035).

CONCLUSIONS

Grade II LALR can be performed with the same level of safety as grade I LALR. However, grade III LALR has a higher complication rate than grades I and II LALR, and the risk increases further due to longer operative time and greater blood loss.

ArtiSential® laparoscopic cholecystectomy versus singlefulcrum laparoscopic cholecystectomy: Which minimally invasive surgery is better?

Backgrounds/Aims

In recent years, many minimally invasive techniques have been introduced to reduce the number of ports in laparoscopic cholecystectomy (LC), offering benefits such as reduced postoperative pain and improved cosmetic outcomes. ArtiSential® is a new multi-degree-of-freedom articulating laparoscopic instrument that incorporates the ergonomic features of robotic surgery, potentially overcoming the spatial limitations of laparoscopic surgery. ArtiSential® LC can be performed using only two ports. This study aims to compare the surgical outcomes of ArtiSential® LC with those of single-fulcrum LC.

Methods

This retrospective study compared ArtiSential® LC and single-fulcrum LC among LCs performed for gallbladder (GB) stones at the same center, analyzing the basic characteristics of patients; intraoperative outcomes, such as operative time, estimated blood loss, and intraoperative GB rupture; and postoperative outcomes, such as length of hospital stay, incidence of postoperative complications, and postoperative pain.

Results

A total of 88 and 63 patients underwent ArtiSential® LC and single-fulcrum LC for GB stones, respectively. Analysis showed that ArtiSential® LC resulted in significantly fewer cases of surgeries longer than 60 minutes (30 vs. 35 min, p = 0.009) and intraoperative GB ruptures (2 vs. 10, p = 0.007). In terms of postoperative outcomes, ArtiSential® LC showed better results in the respective visual analog scale (VAS) scores immediately after surgery (2.59 vs. 3.73, p < 0.001), and before discharge (1.44 vs. 2.02, p = 0.01).

Conclusions

ArtiSential® LC showed better results in terms of surgical outcomes, especially postoperative pain. Thus, ArtiSential® LC is considered the better option for patients, compared to single-fulcrum LC.

Machine learning model-based prediction of postpancreatectomy acute pancreatitis following pancreaticoduodenectomy: A retrospective cohort study

BACKGROUND

The International Study Group of Pancreatic Surgery has established the definition and grading system for postpancreatectomy acute pancreatitis (PPAP). There are no established machine learning models for predicting PPAP following pancreaticoduodenectomy (PD).

AIM

To explore the predictive model of PPAP, and test its predictive efficacy to guide the clinical work.

METHODS

Clinical data from consecutive patients who underwent PD between 2016 and 2024 were retrospectively collected. An analysis of PPAP risk factors was performed, various machine learning algorithms [logistic regression, random forest, gradient boosting decision tree, extreme gradient boosting, light gradient boosting machine, and category boosting (CatBoost)] were utilized to develop predictive models. Recursive feature elimination was employed to select several variables to achieve the optimal machine algorithm.

RESULTS

The study included 381 patients, of whom 88 (23.09%) developed PPAP. PPAP patients exhibited a significantly higher incidence of postoperative pancreatic fistula (55.68% vs 14.68%, P < 0.001), grade C postoperative pancreatic fistula (9.09% vs 1.37%, P = 0.001). The CatBoost algorithm outperformed other algorithms with a mean area under the receiver operating characteristic curve of 0.859 [95% confidence interval (CI): 0.814-0.905] in the training cohort and 0.822 (95%CI: 0.717-0.927) in the testing cohort. According to shapley additive explanations analysis, pancreatic texture, main pancreatic duct diameter, body mass index, estimated blood loss, and surgery time were the most important variables based on recursive feature elimination. The CatBoost algorithm based on selected variables demonstrated superior performance, with an area under the receiver operating characteristic curve of 0.837 (95%CI: 0.788-0.886) in the training cohort and 0.812 (95%CI: 0.697-0.927) in the testing cohort.

CONCLUSION

We developed the first machine learning-based predictive model for PPAP following PD. This predictive model can assist surgeons in anticipating and managing this complication proactively.

Concealed pancreatic cancer in acute pancreatitis: Early MRCP and EUS surveillance improves prognosis and identifies high-risk patients

BACKGROUND/OBJECTIVES

Acute pancreatitis (AP) may obscure small pancreatic cancers (PCs) on computed tomography during the acute phase. Surveillance with magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) may enhance early detection and improve patient outcomes. This study evaluated the impact of early MRCP/EUS surveillance on PC outcomes in AP patients and identified high-risk subgroups for early screening.

METHODS

We retrospectively analyzed 1562 AP patients treated between 2010 and 2021, categorizing them into early surveillance (MRCP/EUS within three months of AP onset; n = 760) and nonearly surveillance groups (n = 802). Key outcomes included time to PC diagnosis, surgical resection rate, tumor stage, and overall survival. Multivariate analysis was performed to identify risk factors for concealed PC in AP patients.

RESULTS

Among 27 PC cases analyzed, the early surveillance group achieved significantly earlier diagnosis, higher surgical resection rates, increased detection of early-stage PC, and improved overall survival compared with the nonearly surveillance group. Multivariate analysis revealed that subthreshold main pancreatic duct (MPD) dilation (≥2.5 mm) and moderately severe AP were significant predictors of PC.

CONCLUSIONS

Early MRCP/EUS surveillance in AP patients facilitates timely detection of occult PC and enhances patient prognosis. These findings support prioritizing early surveillance for AP patients with subthreshold MPD dilation and moderately severe disease. Further large-scale studies are warranted to validate these strategies in clinical practice.

Circulating cyclophilin A levels elevate in animal models and can predict mortality in patients with acute pancreatitis

BACKGROUND/OBJECTIVES

Cyclophilin A (CypA) is released into the blood following cellular injury and correlates with acute pancreatitis (AP) severity, however, investigations into circulating CypA in experimental AP and hypertriglyceridaemia-associated AP (HTG-AP) prevalent cohorts are lacking.

METHODS

C57Bl/6 mice received 4, 8, and 12 caerulein injections to induce escalating severity of AP models (CER-AP). Mice were sacrificed 1 h after the last injection of caerulein to assess severity of CER-AP through biochemical and histopathological analyses, and serum CypA levels were also measured. Golden Syrian hamsters fed with a high-cholesterol/high-fat diet were given 10 caerulein injections to induce experimental HTG-AP to assess severity and serum CypA. Human blood plasma samples taken within 24 h after admission from a patient cohort with a predominance of HTG-AP cases, stored in a prospectively collected AP Biobank, were assessed for plasma CypA levels and correlated with clinical data.

RESULTS

In mice, CER-AP models showed significantly increased pancreatic histopathological scores and biochemical parameters, with severity highest after 12 caerulein injections. Serum CypA levels were significantly higher in all CER-AP models compared to controls. In hamsters, CypA levels were significantly higher in HTG-AP model than controls. In AP patients, CypA levels in non-haemolytic plasma samples varied by aetiology, with the highest levels in HTG-AP, corresponding to HTG levels and AP severity. ROC analysis revealed CypA ≥9.9 ng/ml as a significant predictor of mortality (AUC = 0.865).

CONCLUSION

Circulating CypA levels are significantly increased in mouse CER-AP and hamster HTG-AP models. We have identified a novel association of raised plasma CypA levels with severity of HTG-AP and confirmed its significant prognostic ability to predict mortality in AP patients.

Outcomes of acute pancreatitis in elderly are comparable to those in adults in India: A propensity score-matched analysis

BACKGROUND AND OBJECTIVES

The ageing population is increasing in India and there is hardly any information on outcomes of acute pancreatitis (AP) in the elderly in India. Hence we studied the comprehensive clinical characteristics and outcomes of AP in elderly patients.

METHODS

This study included patients admitted with AP to a tertiary care centre from October 2018 to October 2022. Patients with the first episode of AP presenting within 14 days of disease onset were eligible for inclusion. The elderly population was defined as age ≥ 60 years. Recurrent AP, chronic pancreatitis and AP presenting after 14 days of disease onset were excluded. Propensity score matching was performed based on etiology and severity to compare elderly and non-elderly groups. Primary outcome was serious adverse outcome (SAO: in-hospital mortality or discharge in critical state). Secondary outcomes included organ failures, local complications, necrosis, mesenteric vascular thrombosis (MVT), length of hospital stay, intensive care unit (ICU) admission and infections.

RESULTS

Of 630 eligible patients, 120 were > 60 years of age. Among the elderly, 72 (60%) were males. The median age was 68 (IQR 63-74) years. The most common etiology was biliary 76 (63.3%) followed by idiopathic 25 (20.8%) and alcohol eight (6.7%). Mild AP was seen in 72 (60%), while 21 (17.5%) had moderately severe and 27 (22.5%) had severe AP. Organ failures occurred in 27.5%, necrotizing pancreatitis in 15.2%, local complications in 27.6% and MVT in 3.3%. Infections affected 28.3%. Median hospital stay was four days (IQR 1-28), with 12.5% requiring ICU admission. SAO occurred in 8.3% of elderly patients, comparable to 11.4% in the non-elderly (p = 0.334). Bedside index for severity in acute pancreatitis (BISAP) score (adjusted OR 2.7, 95% CI 1.05-6.96, p = 0.04) and Charlson comorbidity index (without age) (adjusted OR 1.94, 95% CI 1.07-3.51, p = 0.03) independently predicted SAO in the elderly.

CONCLUSION

The outcomes of AP in the elderly in India are similar to patients < 60 years. Charlson comorbidity index and BISAP score predicted serious adverse outcomes in the elderly.

Examining patient-specific responses to PARP inhibitors in a novel, human induced pluripotent stem cell-based model of breast cancer

Preclinical models of breast cancer that better predict patient-specific drug responses are critical for expanding the clinical utility of targeted therapies, including for inhibitors of poly(ADP-ribose) polymerase (PARP). Reprogramming primary cancer cells into human induced pluripotent stem cells (hiPSCs) recently emerged as a powerful tool to model drug response phenotypes, but its use to date has been limited to hematopoietic malignancies. We designed an optimized reprogramming methodology to generate breast cancer-derived hiPSCs (BC-hiPSCs) from nine patients representing all major subtypes of breast cancer. BC-hiPSCs retain patient-specific oncogenic variants, including variants unique to individual tumor subclones. Additionally, we developed a protocol to differentiate BC-hiPSCs into mammary epithelial cells and mammary-like organoids for in vitro disease modeling, including drug response phenotyping. Using these tools, we demonstrated that BC-hiPSCs can be used to screen for differential sensitivity to PARP inhibitors and mechanistically investigated the causal genetic variant driving drug sensitivity in one patient.

COVID-19 infection is a significant risk factor for death in patients presenting with acute cholecystitis: a secondary analysis of the ChoCO-W cohort study

BACKGROUND

During the coronavirus disease (COVID-19) pandemic, there has been a surge in cases of acute cholecystitis. The ChoCO-W global prospective study reported a higher incidence of gangrenous cholecystitis and adverse outcomes in COVID-19 patients. Through this secondary analysis of the ChoCO-W study data, we aim to identify significant risk factors for mortality in patients with acute cholecystitis during the COVID-19 pandemic, emphasizing the role of COVID-19 infection in patient outcomes and treatment efficacy."

METHODS

The ChoCO-W global prospective study reported data from 2546 patients collected at 218 centers from 42 countries admitted with acute cholecystitis during the COVID-19 pandemic, from October 1, 2020, to October 31, 2021. Sixty-four of them died. Nonparametric statistical univariate analysis was performed to compare patients who died and patients who survived. Significant factors were then entered into a logistic regression model to define factors predicting mortality.

RESULTS

The significant independent factors that predicted death in the logistic regression model with were COVID-19 infection (p < 0.001), postoperative complications (p < 0.001), and type (open/laparoscopic) of surgical intervention (p = 0.003). The odds of death increased 5 times with the COVID-19 infection, 6 times in the presence of complications, and it was reduced by 86% with adequate source control. Survivors predominantly underwent urgent laparoscopic cholecystectomy (52.3% vs. 23.4%).

CONCLUSIONS

COVID-19 was an independent risk factor for death in patients with acute cholecystitis. Early laparoscopic cholecystectomy has emerged as the cornerstone of treatment for hemodynamically stable patients.

Relationship Between Serum Levels of Pancreatic Exocrine Enzymes on Admission and Long-Term Clinical Outcomes in Patients with Acute Decompensated Heart Failure

Background/Objectives: Heart failure (HF) can damage organs because of poor perfusion and/or congestion. The interactions between HF and other organs have recently been studied; however, data on the interaction between HF and pancreatic exocrine function, which may affect fat and protein absorption and malnutrition, are scarce. We previously showed that the serum levels of pancreatic exocrine enzymes, as suggestive of pancreatic exocrine function, were low and associated with malnutrition or congestion in hospitalized patients with acute decompensated HF (ADHF). This study investigated the relationship between the serum levels of pancreatic exocrine enzymes and long-term outcomes in patients with ADHF. Methods: We collected serum levels of pancreatic exocrine enzymes (amylase and lipase) from patients who were admitted to the cardiac intensive care unit due to ADHF. Patients undergoing dialysis and those with neoplasms were excluded. Patients were categorized as having high or low pancreatic exocrine enzyme levels in the first quartile upon admission. The association between low serum pancreatic exocrine enzyme levels at admission and the composite of death and ADHF readmission was assessed. Results: Of the 146 patients, 37 (25.3%) and 36 (24.7%) had low amylase and lipase levels, respectively. Patients with low lipase levels showed worse cumulative event-free survival than those with high lipase levels (p < 0.001). A low lipase level was associated with worse outcomes (hazard ratio: 1.96; p = 0.012). Conclusions: These findings suggest that low serum lipase levels may be a predictor of long-term outcomes in patients with ADHF.

MGST1 Protects Pancreatic Ductal Cells from Inflammatory Damage in Acute Pancreatitis by Inhibiting Ferroptosis: Bioinformatics Analysis with Experimental Validation

Numerous animal experiments have implicated ferroptosis in the pathogenesis of acute pancreatitis (AP). Nonetheless, due to sampling constraints, the precise role of ferroptosis in the human body during AP remains elusive. Method: Peripheral blood sequencing data of patients with acute pancreatitis (GSE194331) were obtained from the Gene Expression Omnibus (GEO) database. We analyzed differentially expressed genes whose expression increased or decreased with increasing disease severity and intersected them with the ferroptosis gene set to identify ferroptosis-related driver genes for the disease. The hub genes were selected using machine learning algorithms, and a nomogram diagnosis model was constructed. Clinical samples, animal models, and an in vitro experiment were also used for validation. The investigation unveiled 22 ferroptosis-related driver genes, and we identified three hub genes, AQP3, TRIB2, and MGST1, by employing two machine learning algorithms. AQP3 and TRIB2 exhibit robust correlations with various immune cells. The disease diagnosis model constructed utilizing these three genes demonstrated high sensitivity and specificity (AUC = 0.889). In the in vitro experiments, we discovered for the first time that ferroptosis occurs in pancreatic duct cells during acute pancreatitis, and that MGST1 is significantly upregulated in duct cells, where it plays a crucial role in negatively regulating ferroptosis via the ACSL4/GPX4 axis. In addition, overexpression of MGST1 protects ductal cells from inflammatory damage. In our investigation, we explored the mechanisms of ferroptosis in immune cells and pancreatic duct cells in patients with AP. These results highlight a potential pathway for the early diagnosis and treatment of acute pancreatitis.

Challenges in early career for HPB surgeons: an international practice survey

BACKGROUND

Understanding the needs of early-career surgeons is essential for developing strategies for support. This study examined perceived needs of early-career HPB surgeons worldwide.

METHODS

A self-administered web-based survey of early career HPB surgeons (aged ≤45 years old or practicing for ≤5 years) was conducted. A questionnaire was developed through items generation and reduction, followed by pilot testing. Quantitative data were reported with descriptive statistics and qualitative responses analysed using open coding.

RESULTS

There were 282 respondents. Six main areas of challenges were identified: mentorship opportunities, continued skills acquisition and training, research and collaboration, leadership and career development, clinical knowledge exchange, and accessibility including financial barriers. Specifically, highest rated challenges were ebalancing work and personal life (mean 6.98, SD 2.92), research (mean 6.79, SD 2.50), career development/mentorship (mean 6.70, SD 2.30), networking/collaboration (mean 6.16, SD 2.71), leadership and (mean 6.09, SD 2.53). Rating of research as a challenge was higher in Africa and Central/South America (p = 0.01), and that of leadership was higher in Asia, Oceania, and the Middle East (p = 0.02).

CONCLUSIONS

This survey highlights the multiple challenges faced by early-career HPB surgeons worldwide. These results provide insights into how to better support early-career HPB surgeons to fully develop their specialty.

Unlocking Fertility: How Nitric Oxide Pathways Connect Obesity and Reproductive Health-The Role of Bariatric Surgery

This study examines the relationship between obesity, oxidative stress, and reproductive dysfunction. It focuses on the effects of sleeve gastrectomy on gene expression and hormone profiles in 29 women with severe obesity (BMI ≥ 40 kg/m2). Pre- and post-surgical investigations revealed significant differences in major gene expressions and hormonal markers. CART expression reduced significantly from 0.27 ± 4.43 to -3.42 ± 1.14 (p < 0.001), while leptin expression decreased from -1.87 ± 1.75 to -0.13 ± 1.55 (p < 0.001), indicating better metabolic regulation. In contrast, eNOS expression increased considerably from -4.87 ± 1.70 to 1.18 ± 2.31 (p = 0.003), indicating improved endothelial function and nitric oxide bioavailability, which is critical for vascular health and reproduction. Correlation research before surgery indicated no significant relationships between eNOS, CART, or leptin and clinical indicators, implying that these genes function independently in pre-surgical metabolism. While most associations remained negligible after surgery, a significant negative connection between eNOS expression and SHBG levels appeared (r = -0.365, p = 0.049), indicating potential interactions in hormonal regulation pathways following metabolic improvements. These findings emphasize the importance of bariatric surgery in reducing the negative effects of obesity on reproductive health by altering critical cellular pathways. Significant increases in CART, leptin, and eNOS expression indicate reduced oxidative stress, improved vascular tone, and hormonal balance, all of which contribute to increased reproductive capacity. This study sheds light on the molecular processes that link obesity, metabolic health, and fertility, underlining bariatric surgery's therapeutic potential for women experiencing obesity-related infertility.

Atypical hemolytic uremic syndrome triggered by acute pancreatitis

The clinical manifestations of atypical hemolytic uremic syndrome （aHUS） are hemolytic anemia, thrombocytopenia, and acute kidney injury. It is one of the Thrombotic microangiopathy (TMA), with triggers for activation of the complement bypass pathway, such as infection and pregnancy, present in 70-80% of patients. Treatment for this disease requires plasma exchange or eculizumab, we encountered a patient with aHUS induced by gallstone-pancreatitis, after the initial plasma exchange, the patient's condition was improved, but the subsequent incomplete treatment eventually led to severe sequelae. In a word, early, correct and adequate treatment is critical to the prognosis of these patients.

Comprehensive management of gastrointestinal fistulas in necrotizing pancreatitis: a review of diagnostic and therapeutic approaches

INTRODUCTION

Gastrointestinal fistula (GIF) is a rare but severe complication in patients with necrotizing pancreatitis (NP), significantly prolonging disease course and increasing morbidity and mortality. Its subtle and nonspecific early symptoms often delay diagnosis and intervention. Despite its clinical significance, the low incidence of GIF in NP has resulted in limited research and a lack of consensus on optimal diagnostic and therapeutic strategies.

AREAS COVERED

This review focuses on the epidemiology, pathophysiology, diagnostic approaches, and therapeutic management of GIF in NP patients. Imaging techniques, such as contrast-enhanced computed tomography and endoscopy, have been integral to early diagnosis. Advances in interventional and surgical techniques provide new avenues for treatment, but variability in clinical practice highlights the need for standardized protocols.

EXPERT OPINION

Recent advances in diagnostic imaging have improved the detection of GIF, while innovations in interventional and surgical treatments show promise. Current research is still insufficient and varied. Future research should focus on developing diagnostic methods and treatment measures for such complications. By improving early diagnosis and offering insights into effective management strategies, it is hoped that patient outcomes can be improved.

Visceral adiposity index as a key predictor of severity in acute pancreatitis - A large-scale retrospective cohort study

BACKGROUND AND AIMS

Visceral adipose tissue has been indicated closely connected with the severity of acute pancreatitis (AP). Visceral adiposity index (VAI) is a mathematical model that consists of waist circumference, body mass index, triglyceride and high-density lipoprotein cholesterol, which has been demonstrated to be a better indicator of visceral fat than other traditional indices. This study aimed to evaluate the relationship between VAI and the severity of AP.

METHODS

A retrospective analysis was conducted on a cohort of 1174 patients diagnosed with AP. These patients were categorized into two groups based on their VAI values: the normal VAI (NVAI) group and the elevated VAI (EVAI) group.

RESULTS

The EVAI group were much younger, mainly male and had higher incidence of severe acute pancreatitis (SAP) compared with the NVAI group (p < 0.001). The EVAI group developed higher incidences of persistent respiratory failure, acute peripancreatic fluid collection (APFC) and acute necrotic collection (ANC). The VAI level and the percentage of EVAI showed an increasing trend with the severity of AP (p < 0.001). EVAI was the most independent risk factor for persistent respiratory failure (OR = 6.405, 95% CI 2.317-17.705), APFC (OR = 2.093, 95% CI 1.255-3.578) and ANC (OR = 4.910, 95% CI 1.736-13.887).

CONCLUSIONS

EVAI was strongly related to the severity of AP. It was the most independent risk factor of persistent respiratory failure, APFC and ANC.

Impact of Sepsis Onset Timing on All-Cause Mortality in Acute Pancreatitis: A Multicenter Retrospective Cohort Study

BACKGROUND

Sepsis complicates acute pancreatitis (AP), increasing mortality risk. Few studies have examined how sepsis and its onset timing affect mortality in AP. This study evaluates the association between sepsis occurrence and all-cause mortality in AP, focusing specifically on the impact of sepsis onset timing.

METHODS

This multicenter retrospective cohort study included 494 ICU-admitted AP patients from the MIMIC-IV database and 91 from our center. Patients were grouped by sepsis occurrence and onset timing. Clinical outcomes were in-hospital and 90-day all-cause mortality. Machine learning identified key variables associated with mortality. Multivariable regression analyzed the impact of sepsis and its onset timing on mortality. To reduce baseline differences, propensity score matching (PSM) based on time to sepsis was conducted. After PSM, Kaplan-Meier survival analyses incorporated data from our center for validation. Restricted cubic spline analysis examined any nonlinear relationship between sepsis onset timing and mortality.

RESULTS

Patients with sepsis had significantly higher in-hospital and 90-day mortality rates than those without sepsis (p < 0.05). Sepsis was identified as a significant risk factor for in-hospital mortality and remained significantly associated after adjusting for key variables (p < 0.05). However, sepsis onset timing did not significantly impact in-hospital or 90-day mortality. These findings were validated after PSM and with our center's data. No nonlinear relationship between sepsis onset timing and mortality was found.

CONCLUSION

Sepsis significantly increases all-cause mortality in AP patients, but the timing of its onset has limited impact. Continuous monitoring and intervention for sepsis during hospitalization are recommended to improve prognosis.

Risk factors and incidence of unplanned re-operation after transumbilical single-hole laparoscopic appendectomy in children

Purpose

This study aims to investigate the factors associated with unplanned re-operations (UR) following transumbilical single-hole laparoscopic appendectomy (TUSILA) in pediatric patients.

Methods

We conducted a retrospective analysis of clinical data from children diagnosed with acute appendicitis (AA) who underwent TUSILA at our center between January 2020 and January 2024. All the operations were performed under single-port laparoscopy, including two methods of appendectomy, intra-TUSILA and extra-TUSILA. Patients were categorized into the UR and control groups to compare baseline characteristics, clinical data, postoperative management, and surgical outcomes.

Results

The study included 188 patients (110 males and 78 females), with 4 (2.1%) in the UR group. Within the UR group, three cases (75%) necessitated re-operation due to adhesive intestinal obstruction, while one case (25%) was due to an appendiceal remnant fistula. The baseline characteristics, operation duration, intraoperative blood loss, surgeon experience, and postoperative fasting times showed no significant difference between the two groups (all P > 0.05). However, the incidences of procedures beyond standard TUSILA, lateral peritoneum lysis, appendiceal perforation, complicated appendicitis as confirmed by pathology, drainage tube placement, and the length of antibiotic duration were significantly higher in the UR group compared to the control group (all P < 0.05).

Conclusion

A notable percentage of pediatric patients undergoing TUSILA experience UR, primarily due to adhesive ileus, with a substantial proportion potentially linked to surgical technical errors and postoperative management.

Gender, race and ethnicity biases experienced by hospital physicians: an umbrella review to explore emerging biases in the evidence base

OBJECTIVES

To examine the authorship and content of systematic reviews (SRs) of biases experienced by medical professionals through a gender lens.

DESIGN

Review of SRs.

DATA SOURCES

We searched PubMed, Embase, PsycINFO and CINAHL from inception. Searches were conducted in May 2022 and updated in October 2023.

ELIGIBILITY CRITERIA

Reviews of studies reporting biases experienced by hospital physicians at any stage of their careers and in any country. Reviews were included if they used systematic methods to search the literature and synthesise the data. Non-English language publications were excluded.

DATA EXTRACTION AND SYNTHESIS

The main theme of each eligible review was identified through qualitative thematic analysis. We used NamSor to determine the first/last authors' gender and computed the proportion of female authors for each review theme.

RESULTS

56 articles were included in the review. These covered 12 themes related to gender, race and ethnicity bias experienced by physicians at any stage of their careers. The overall proportion of female authors was 70% for first authors and 51% for last authors. However, the gender of authors by theme varied widely. Female authors dominated reviews of research on discrimination and motherhood, while male authors dominated reviews on burnout, mental health and earnings. Only six reviews were identified that included race and ethnicity; 9 out of the 12 first and last authors were female.

CONCLUSIONS

Understanding the potential for a gendered evidence base on biases experienced by hospital physicians is important. Our findings highlight apparent differences in the issues being prioritised internationally by male and female authors, and a lack of evidence on interventions to tackle biases. Going forward, a more collaborative and comprehensive framework is required to develop an evidence base that is fit for purpose. By providing a point of reference, the present study can help this future development.

PROSPERO REGISTRATION NUMBER

CRD42021259409; Pre-results.

Characterization and comparison of gut microbiota in patients with acute pancreatitis by metagenomics and culturomics

Acute pancreatitis (AP) is a common gastrointestinal disorder with a high mortality rate. This study sought to identify the microbial community structure in patients with AP using metagenomics and culturomics. Compared to healthy controls, patients with AP exhibited a significant decrease in alpha diversity; a higher abundance of unclassified Enterococcus species (sp), Enterococcus faecium, and Enterococcus faecalis; and a lower abundance of Eubacterium rectale. A total of 336 isolates from 25 genera and 44 species were obtained by sample cultivation. The dominant species identified in patients with AP were Enterococcus faecium and Klebsiella grimontii, whereas those in the healthy controls were Enterococcus faecium, Escherichia coli, and Bacteroides faecis. Our research has contributed to the expanded understanding of the genome, diversity, and function of the intestinal microbiota in patients with AP and provided some reference for selecting culture medium and sample processing methods.

Pancreatic endocrine and exocrine signaling and crosstalk in physiological and pathological status

The pancreas, an organ with dual functions, regulates blood glucose levels through the endocrine system by secreting hormones such as insulin and glucagon. It also aids digestion through the exocrine system by secreting digestive enzymes. Complex interactions and signaling mechanisms between the endocrine and exocrine functions of the pancreas play a crucial role in maintaining metabolic homeostasis and overall health. Compelling evidence indicates direct and indirect crosstalk between the endocrine and exocrine parts, influencing the development of diseases affecting both. From a developmental perspective, the exocrine and endocrine parts share the same origin-the "tip-trunk" domain. In certain circumstances, pancreatic exocrine cells may transdifferentiate into endocrine-like cells, such as insulin-secreting cells. Additionally, several pancreatic diseases, including pancreatic cancer, pancreatitis, and diabetes, exhibit potential relevance to both endocrine and exocrine functions. Endocrine cells may communicate with exocrine cells directly through cytokines or indirectly by regulating the immune microenvironment. This crosstalk affects the onset and progression of these diseases. This review summarizes the history and milestones of findings related to the exocrine and endocrine pancreas, their embryonic development, phenotypic transformations, signaling roles in health and disease, the endocrine-exocrine crosstalk from the perspective of diseases, and potential therapeutic targets. Elucidating the regulatory mechanisms of pancreatic endocrine and exocrine signaling and provide novel insights for the understanding and treatment of diseases.

Indocyanine green fluorescence-guided surgery in the emergency setting: the WSES international consensus position paper

BACKGROUND

Decision-making in emergency settings is inherently complex, requiring surgeons to rapidly evaluate various clinical, diagnostic, and environmental factors. The primary objective is to assess a patient's risk for adverse outcomes while balancing diagnoses, management strategies, and available resources. Recently, indocyanine green (ICG) fluorescence imaging has emerged as a valuable tool to enhance surgical vision, demonstrating proven benefits in elective surgeries.

AIM

This consensus paper provides evidence-based and expert opinion-based recommendations for the standardized use of ICG fluorescence imaging in emergency settings.

METHODS

Using the PICO framework, the consensus coordinator identified key research areas, topics, and questions regarding the implementation of ICG fluorescence-guided surgery in emergencies. A systematic literature review was conducted, and evidence was evaluated using the GRADE criteria. A panel of expert surgeons reviewed and refined statements and recommendations through a Delphi consensus process, culminating in final approval.

RESULTS

ICG fluorescence imaging, including angiography and cholangiography, improves intraoperative decision-making in emergency surgeries, potentially reducing procedure duration, complications, and hospital stays. Optimal use requires careful consideration of dosage and timing due to limited tissue penetration (5-10 mm) and variable performance in patients with significant inflammation, scarring, or obesity. ICG is contraindicated in patients with known allergies to iodine or iodine-based contrast agents. Successful implementation depends on appropriate training, availability of equipment, and careful patient selection.

CONCLUSIONS

Advanced technologies and intraoperative navigation techniques, such as ICG fluorescence-guided surgery, should be prioritized in emergency surgery to improve outcomes. This technology exemplifies precision surgery by enhancing minimally invasive approaches and providing superior real-time evaluation of bowel viability and biliary structures-areas traditionally reliant on the surgeon's visual assessment. Its adoption in emergency settings requires proper training, equipment availability, and standardized protocols. Further research is needed to evaluate cost-effectiveness and expand its applications in urgent surgical procedures.

Minimally Invasive Rectal Surgery: Current Status and Future Perspectives in the Era of Digital Surgery

Over the past two decades, minimally invasive approaches in rectal surgery have changed the landscape of surgical interventions, impacting both malignant and benign pathologies. The dynamic nature of rectal cancer treatment owes much to innovations in surgical techniques, reflected in the expanding literature on available treatment modalities. Local excision, facilitated by minimally invasive surgery, offers curative potential for patients with early T1 rectal cancers and favorable pathologic features. For more complex cases, laparoscopic and robotic surgery have demonstrated significant efficacy and provided precise, durable outcomes while reducing perioperative morbidity and enhancing postoperative recovery. Additionally, advancements in imaging, surgical instrumentation, and enhanced recovery protocols have further optimized patient care. The integration of multidisciplinary care has also emerged as a cornerstone of treatment, emphasizing collaboration among surgeons, oncologists, and radiologists to deliver personalized, evidence-based care. This narrative review aims to elucidate current minimally invasive surgical techniques and approaches for rectal pathologies, spanning benign and malignant conditions, while also exploring future directions in the field, including the potential role of artificial intelligence and next-generation robotic platforms.

Early enteral nutrition with fructooligosaccharides improves prognosis in severe acute pancreatitis

Soluble dietary fiber, notably as an adjunct to early enteral nutrition (EEN), is gaining prominence in clinical therapy. This study evaluates the effect of fructooligosaccharides (FOS), a new soluble dietary fiber, on the prognosis of patients with severe acute pancreatitis (SAP). In a retrospective cohort study at the Third Xiangya Hospital of Central South University from July 2017 to July 2023, 110 SAP patients were analyzed. TPF (enteral nutritional suspension of total protein)-normal and TPF-FOS groups both received standard EEN solutions; the latter additionally received FOS. Outcomes were compared between the groups. The study included 37 patients in the TPF-FOS group and 73 patients in the TPF-normal group. Mortality was 13.50% in the TPF-FOS group and 34.20% in the TPF-normal group (P < 0.05). FOS was identified as an independent protective factor (OR: 0.826, P = 0.041). The TPF-FOS group showed lower rates of intra-abdominal infection and decreased the level of inflammation (P < 0.05). FOS potentially acts as an independent protective factor against death in SAP. Additionally, the supplementation of EEN with FOS may contribute to reducing mortality and improving the prognosis of SAP patients.

Microbial dynamics of acute pancreatitis: integrating culture, sequencing, and bile impact on bacterial populations and gaseous metabolites

Background

Our study examined the composition of the intestinal microflora in a hospitalized patient with AP symptoms treated several months earlier for diverticulitis. The therapeutic intervention necessitated Hartmann's procedure, culminating in colostomy creation.

Aims

Employing a thorough microbiological analysis we attempted to demonstrate whether the microflora isolated from the peripancreatic fluid exhibited a stronger correlation with the contents of the stoma or with the rectal swab. Additionally, we sought to determine the association between later onset of AP and diverticulitis.

Methods

Following clinical materials from the patient in the initial phase of AP were collected: rectal swab, colostomy bag contents (in the publication referred to as stoma content/stool) and peripancreatic fluid. Microbiological analysis was performed, including classic culture methodology, NGS techniques, and genotyping methodologies. Furthermore, the effect of bile on the shift in the population of selected bacterial species was examined.

Results

The NGS technique confirmed greater consistency in bacteria percentage (phyla/family) between stoma content and peripancreatic fluid. In both samples, a clear dominance of the Proteobacteria phyla (over 75%) and the Enterobacteriaceae family was demonstrated. Moreover, NGS verified the presence of the Fusobacteriota phylum and Fusobacteriaceae family only in rectal swabs, which may indicate a link between this type of bacteria and the etiology of diverticulitis. We observed that Escherichia coli 33 isolated from stool exhibited active gaseous metabolite production (mainly hydrogen).

Conclusions

The abundant production of hydrogen may substantially impact enzymatic processes, inducing specific alterations in disulfide bonds and trypsin inactivation. Our investigation alludes to the conceivable active involvement of bile in effecting qualitative and quantitative modifications in the peripancreatic microbiota composition, establishing a correlation between released bile and bacterial generation of gaseous metabolites.

Construction and interpretation of weight-balanced enhanced machine learning models for predicting liver metastasis risk in colorectal cancer patients

BACKGROUND

Colorectal cancer (CRC) is a major contributor to cancer-related mortality, with liver metastases developing in approximately 25% of affected individuals. The presence of liver metastasis significantly deteriorates the prognosis for patients. The objective of this study is to predict liver metastasis in CRC patients by developing machine learning (ML)-based models, thereby aiding clinicians in the decision-making process for appropriate interventions.

METHODS

Retrospective analysis was performed using the Surveillance, Epidemiology, and End Results (SEER) database, and cases with CRC from 2010 to 2015 were extracted to the downstream analysis. Logistic regression (LR), Random Forest (RF), Gradient Boosting Machine (GBM), Extreme Gradient Boosting (XGBoost), Categorical Boosting (CatBoost), and LightGBM are applied to develop machine learning (ML) models to predict liver metastasis of CRC patient. To optimize the models, an improved weight-balancing algorithm was employed, enhancing the performance of the classifiers. The six models were tenfold cross-validated, and the optimal model was selected based on a combination of performance metrics. Shapley additive explanation (SHAP) was utilized to interpret the best-performing ML models globally, locally, and interactively. To ensure the model's reliability and generalizability, an external validation cohort of CRC cases from 2018 to 2021, obtained from a separate SEER database, was used for external evaluation.

RESULTS

In total, 50,062 patients with CRC were included in the analysis, with 5604 patients occurring liver metastasis. Among the six models evaluated, the CatBoost model showed excellent performance with the highest AUC of 0.8844. Moreover, the CatBoost model also outperformed the others in terms of recall (0.8060) and F1-score (0.6736). SHAP-based summary and force plots were used to interpret the CatBoost model. The interpretability analysis revealed that elevated carcinoembryonic antigen (CEA) levels, systemic therapy, N and T stages, and chemotherapy performed were the most significant indicators for predicting liver metastasis according to the optimal model. Furthermore, systemic therapy was suggested to increase liver metastasis risk in N0 stage patients, while it appeared to be beneficial in patients with lymph node metastasis. Preoperative radiation therapy was found to be more effective than postoperative radiation therapy. Validation using an external cohort of CRC cases from 2018 to 2021 further confirmed the robustness and stability of the CatBoost model, as its overall performance remained consistent with the internal validation results.

CONCLUSION

Elevated levels of carcinoembryonic antigen (CEA) have been identified as a crucial clinical predictor for liver metastasis in CRC patients. Furthermore, the administration of systemic therapy to patients who do not exhibit lymph node involvement has been found to increase the risk of liver metastasis. In terms of radiation therapy, preoperative radiation appears to be more efficacious in controlling the risk of liver metastasis compared to postoperative radiation. This finding underscores the importance of optimizing treatment strategies based on the specific clinical context and patient characteristics.