Objective:. Despite radical resection, postoperative recurrence of nonfunctional pancreatic neuroendocrine tumors (NF-PanNETs) remains common, particularly among high-risk patients. This study evaluates the adjuvant therapeutic potential of Qizhen Yiliu Formula (QZYL) in a multicenter real-world cohort. Methods:. We retrospectively analyzed patients with NF-PanNETs treated at 5 tertiary centers in China between 2010 and 2022. Patients were divided into QZYL and control groups based on receipt of QZYL as postoperative adjuvant therapy. Baseline differences were adjusted using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) sensitivity analysis. Three hundred and eighty-five eligible patients were analyzed, with 112 matched pairs. Results:. QZYL treatment was associated with longer recurrence-free survival (RFS) compared with controls (median: 78.0 vs 71.9 months; hazard ratio [HR] = 0.60, P = .027), with higher 24-, 36-, and 60-month RFS rates (90.92% vs 80.36%, 86.14% vs 70.07%, 64.97% vs 55.56%, respectively). Subgroup analyses demonstrated trends favoring QZYL across high-risk strata (Ki-67 index 10%–20%, tumor size ≥4 cm, lymph node metastasis, and pathological invasion), although statistical significance varied between PSM and IPTW analyses. Among patients receiving other adjuvant therapies, QZYL use was associated with improved outcomes (HR = 0.56, P = .070). Safety analysis indicated that QZYL did not increase the overall incidence of adverse events (P = .847) and was associated with a lower incidence among patients receiving other adjuvant therapies (P = .010). Conclusions:. QZYL use was associated with a reduced risk of postoperative recurrence in patients with high-risk NF-PanNET, suggesting its role in postoperative management. Prospective validation is warranted.

BACKGROUND:Metabolic syndrome (MS) influences the development of pancreatic ductal adenocarcinoma (PDAC), but its effect on oncological outcomes remains unclear. This study aimed to investigate the role of MS in the patients' perioperative and long-term oncological outcomes. METHODS:Patients undergoing R0 resection of PDAC in seven centers from June 2015 to May 2022 were included. A propensity score matching (PSM) was performed to eliminate confounders between the groups. Perioperative outcomes of patients with and without MS were compared. Additionally, the prognosis was analyzed separately for the MS subgroup and the tumor site subgroup. RESULTS:Of 1548 patients, 388 (25.1%) had MS. After PSM, 1071 patients were enrolled in a 1:2 ratio. Compared with non-MS patients, MS patients had significantly higher rates of major complications, including grade B/C delayed gastric emptying and grade B/C postoperative pancreatic fistula, 90-day readmission, 90-day mortality (all P < 0.05), worse overall survival (OS) (22.7 vs. 31.5 months, P < 0.001) and recurrence-free survival (RFS) (11.9 vs. 15.8 months, P < 0.001). Multivariate analysis revealed that MS, carbohydrate antigen 19-9 > 37 U/mL, lymphatic metastasis, and major complications were independent risk factors for OS and RFS. In the subgroup analysis, patients in the high-risk MS group (4 or 5 components) showed shorter OS (20.6 vs. 23.8 months, P < 0.05) and RFS (11.1 vs. 12.6 months, P < 0.05) than patients in the low-risk MS group (3 components). Combined diabetes mellitus, obesity, and dyslipidemia in PDAC patients yielded the poorest OS and RFS outcomes following R0 resection. CONCLUSIONS:Perioperative and oncological prognosis was significantly worse in PDAC patients with MS after R0 resection. Patients experienced worse long-term survival outcomes with the increase in the number of MS components. PDAC patients with diabetes mellitus, obesity, and dyslipidemia should undergo closer follow-up monitoring after R0 resection.

BackgroundGiven the growing interest in the influence of lymph node metastasis on the prognosis of patients diagnosed with pancreatic head cancer (PHC). This study aims to evaluate the ability of current four nodal staging systems predicting long-term outcomes and develop a machine learning model for predicting the prognosis of patients with resectable PHC.Materials and methodsParticipants with PHC were sourced from the Surveillance, Epidemiology, and End Results (SEER) database and allocated at random in a 7:3 ratio to training and internal validation cohort. External validation in a large-sample, multicenter cohort collected from three Chinese institutions was performed to verified the robustness of the optimal nodal staging system and predictive model. The concordance index (C-index), Akaike information criterion (AIC) and area under the curve (AUC) were calculated to evaluate the predictive capability and discrimination of different nodal staging systems. The machine learning procedures based procedure and Cox regression analysis were implemented for identification of the prognostic factors and construction of predictive model. The calibration curves, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) and decision curve analysis (DCA) were using to assess predictive accuracy and clinical benefits of the predictive model.ResultsAll four nodal staging systems were independent prognostic factors for overall survival (OS). The log odds of lymph node ratio (LODDS) were verified as the optimal nodal staging system with highest C-index and AUCs, and lowest AICs compared to others, and has better predictive capability than others both in patients with < 12 and ≥ 12 retrieval lymph nodes (RLNs). Then, a predictive model including T stage, tumor differentiation, chemotherapy, and LODDS was developed and validated. This model had a higher C-index and AUCs than the AJCC staging system. The NRI, IDI, and DCA analysis also indicated that present model had good predictive capability and clinical utility.ConclusionThe nodal staging system LODDS is the optimal prognostic factor for OS in resectable PHC. It could effectively predict OS for resectable PHC patients without considering the numbers of RLN. The machine learning model could effectively predict OS for patients with resectable PHC.

Background:Pancreaticoduodenectomy (PD) is the only potentially curative treatment for distal cholangiocarcinoma (DCC). This multicenter propensity score matching (PSM) study aimed to compare the perioperative and oncological outcomes of laparoscopic PD (LPD) and robotic PD (RPD) after the learning curve of surgeons. Methods:Consecutive patients with DCC who underwent curative LPD or RPD at eight Chinese centers between January 2016 and December 2022 were included. PSM was performed to minimize selection bias. Univariate and multivariate logistic regression analyses were used to identify independent prognostic factors for textbook outcome (TO) in these patients. Results:Overall, 529 patients who underwent PD for DCC were included, of which 251 underwent LPD and 278 underwent RPD. After PSM, 227 patients were enrolled into each group. There were no significant differences in estimated blood loss (EBL), lymph node harvest, intraoperative transfusion, vascular resection, R0 resection, severe complications, readmission, 30-day mortality, or long-term survival between the two groups. However, after the learning curve, RPD had a perioperative advantage over LPD, especially in terms of operation time (270 vs. 300 min, P<0.001). Similar conclusions were drawn in the subgroup analysis. Multivariable analysis showed that comorbidities (P=0.001), main pancreatic duct (MPD) >3 mm (P=0.001), and operative time >360 min (P=0.006) were significantly associated with TO. Conclusions:After the surgeon's learning curve, the feasibility and safety of LPD and RPD for DCC patients are comparable. Randomized controlled trials (RCTs) should be performed to confirm these findings.

BACKGROUND:The risk of pancreatic ductal adenocarcinoma (PDAC) is increased in patients with diabetes mellitus (DM), particularly in new-onset diabetes (NOD). This study aimed to analyze the effect of NOD on the outcomes of patients with PDAC after R0 resection. METHODS:PDAC patients from six centers in China undergoing R0 resection from 2015 to 2022 were included. Patients were categorized as long-term diabetes (LTD), NOD, or non-diabetes mellitus (non-DM) based on the timing of diagnosis relative to pancreatic resection. We compared the effects of diabetes status on perioperative and oncological outcomes of PDAC. RESULTS:Of 1211 patients, 602 (49.7%), 127 (10.5%), and 482 (39.8%) were in the non-DM, LTD, and NOD groups, respectively. Patients with NOD suffered from higher rates of fatty pancreas and postoperative pancreatic fistula (POPF) (both P < 0.05). When compared with the non-DM group, the NOD group had worse median overall survival (OS) (24.6 vs. 29.4 months, P < 0.001) and recurrence-free survival (RFS) (13.3 vs. 15.8 months, P < 0.001); and the LTD group also had worse median OS (25.2 vs. 29.4 months, P = 0.041) and RFS (13.8 vs. 15.8 months, P = 0.007) compared with non-DM group. However, there were no significant differences in survival between the NOD and the LTD groups. Multivariate analysis indicated that NOD, LTD, largest tumor size, and poor tumor differentiation were independently associated with worse OS and RFS (all P < 0.05). CONCLUSIONS:Patients with PDAC undergoing R0 resection experienced a higher probability of POPF in the presence of concurrent NOD. Long-term survival prognosis was worse in NOD or LTD patients than in non-DM patients.

Objective:This study aimed to compare robotic pancreatoduodenectomy (RPD) with laparoscopic pancreatoduodenectomy (LPD) in operative and oncologic outcomes. Background:Previous studies comparing RPD with LPD have only been carried out in small, single-center studies with variable quality. Methods:Consecutive patients from nine centers in China who underwent RPD or LPD between 2015 and 2022 were included. A 1:1 propensity score matching (PSM) was used to minimize bias. Results:Of the 2255 patients, 1158 underwent RPD, and 1097 underwent LPD. After PSM, 1006 patients were enrolled in each group. The RPD group had significantly shorter operative time (270.0 vs 305.0 minutes, P<0.001), lower intraoperative blood transfusion rate (5.9% vs 12.0%, P<0.001), lower conversion rate (3.8% vs 6.7%, P=0.004), and higher vascular reconstruction rate (7.9% vs 5.6%, P=0.040) than the LPD group. There were no significant differences in estimated blood loss, postoperative length of stay, perioperative complications, and 90-day mortality. Patients who underwent vascular reconstruction had similar outcomes between the 2 groups, although they had significantly lower estimated blood loss (300.0 vs 360.0 mL; P=0.021) in the RPD group. Subgroup analysis on pancreatic ductal adenocarcinoma found no significant differences between the 2 groups in median recurrence-free survival (14.3 vs 15.3 mo, P=0.573) and overall survival (24.1 vs 23.7 mo, P=0.710). Conclusions:In experienced hands, both RPD and LPD are safe and feasible procedures with similar surgical outcomes. RPD had a perioperative advantage over LPD, especially in vascular reconstruction. For pancreatic ductal adenocarcinoma patients, RPD resulted in similar oncological and survival outcomes as LPD.

Medical image segmentation is essential for clinical diagnosis, surgical planning, and treatment monitoring. Traditional approaches typically strive to tackle all medical image segmentation scenarios via one-time learning. However, in practical applications, the diversity of scenarios and tasks in medical image segmentation continues to expand, necessitating models that can dynamically evolve to meet the demands of various segmentation tasks. Here, we introduce EvoSAM, a dynamically evolving medical image segmentation model that continuously accumulates new knowledge from an ever-expanding array of scenarios and tasks, enhancing its segmentation capabilities. Extensive evaluations on surgical image blood vessel segmentation and multi-site prostate MRI segmentation demonstrate that EvoSAM not only improves segmentation accuracy but also mitigates catastrophic forgetting. Further experiments conducted by surgical clinicians on blood vessel segmentation confirm that EvoSAM enhances segmentation efficiency based on user prompts, highlighting its potential as a promising tool for clinical applications.

Objective:To conduct preliminary evaluation of the reliability and safety of pancreatic duct-to-jejunum stent-bridging internal drainage as a supplementary approach to pancreaticojejunostomy in central pancreatectomy. Methods:The clinical data of 28 patients who underwent robotic central pancreatectomy performed by our team between January 2021 and November 2024 were retrospectively collected, and and follow-up of postoperative endocrine and exocrine functions was performed. Based on the methods of digestive tract reconstruction adopted, the patients were divided into a conventional pancreaticojejunostomy group and a pancreatic duct-to-jejunum stent-bridging internal drainage group (PancreaticoJejunal-Stent bridge group). The operative time, digestive tract reconstruction time, and short-term complications were compared between the two groups. Results:Among patients undergoing robotic central pancreatectomy, the digestive tract reconstruction time was shorter (t = 5.168, P < 0.001) in the PancreaticoJejunal-Stent bridge group ([31.1 ± 6.3] min) than that in the conventional pancreaticojejunostomy group ([49.7 ± 8.9] min) (t = 5.168, P < 0.001). The total operative time was (172.7 ± 64.6) min in the PancreaticoJejunal-Stent bridge group and (200.1 ± 52.7) min in the conventional pancreaticojejunostomy group, showing no statistically significant difference (t = 1.215, P = 0.235). In the PancreaticoJejunal-Stent bridge group, one patient developed a postoperative biochemical fistula, and 14 patients developed grade B pancreatic fistulas. Among the 14 patients with grade B pancreatic fistulas, 1 case was complicated by fistula-related intra-abdominal infection, and 13 cases had drainage tube retention time of more than 21 days. In the conventional pancreaticojejunostomy group, 2 patients developed postoperative biochemical fistulas, and 11 patients developed grade B pancreatic fistulas. Among the 11 patients with grade B pancreatic fistulas, 1 case was complicated by fistula-related intra-abdominal infection, and 1 case was complicated by fistula-related intra-abdominal bleeding and infection. No postoperative gastroparesis, pancreatitis, or grade C pancreatic fistulas occurred in either group. There were no statistically significant differences between the two groups in overall postoperative complication rate (P = 0.522), postoperative pancreatic fistula rate (P = 0.583), intra-abdominal infection rate (P = 0.583), or bleeding rate (P = 0.464). Conclusion:Pancreatic duct-to-jejunum stent-bridging internal drainage optimizes the anastomosis between the distal end of the pancreas and the jejunum during central pancreatectomy, shortens digestive tract reconstruction time, and reduces surgical complexity without increasing the risk of short-term severe postoperative complications. This approach is safe and feasible.

Robotic-assisted hepatopancreatobiliary (HPB) surgery is increasingly adopted in high-volume centers. This study evaluated the feasibility, safety, and technical characteristics of the Toumai® robotic system in HPB surgery. We retrospectively analyzed 160 consecutive patients who underwent HBP surgery using the Toumai® system at the Chinese People’s Liberation Army General Hospital between November 2024 and June 2025. Procedures included liver resection (92 cases: 32 lobectomies/segmentectomies and 60 local resections), pancreatic surgery (23 cases: 2 pancreaticoduodenectomies, 9 distal pancreatectomies, 11 tumor resections, 1 pancreatic duct incision and pancreaticojejunostomy), and biliary surgery (37 cases: 3 radical resections for hilar cholangiocarcinoma, 23 biliary explorations and stone removals, 6 gallbladder cancer resections, 3 choledochojejunostomies, and 2 cholecystectomies). Of the cohort, 46 patients (28.8

Minimally invasive spleen-preserving distal pancreatectomy (SPDP) presents technical challenges and remains a topic of debate. This study seeks to compare the splenic preservation techniques, especially the Kimura and Warshaw methods, with distal pancreatectomy with splenectomy (DPS) and to examine factors influencing short-term patient prognostic outcomes. A retrospective analysis was undertaken of all consecutive cases of minimally invasive distal pancreatectomy, both with and without spleen preservation, conducted at our center from January 2020 to May 2024. The study assessed the impact of demographic characteristics, operative variables, oncologic pathology review, and postoperative outcomes on patients’ prognosis. Propensity score matching (PSM) was conducted at a 1:1 ratio. Both univariate and multivariate analyses were performed to identify risk factors affecting the preservation of the spleen and splenic vessels during distal pancreatectomy. The research encompassed data from 490 consecutive patients who underwent minimally invasive distal pancreatectomy. Among the groups with planned spleen-preserving operations, after PSM, the incidence of Clavien-Dindo classification (CDC) ≥ III (6.3

Blood vessel and surgical instrument segmentation is a fundamental technique for robot-assisted surgical navigation. Despite the significant progress in natural image segmentation, surgical image-based vessel and instrument segmentation are rarely studied. In this work, we propose a novel self-supervised pretraining method (SurgNet) that can effectively learn representative vessel and instrument features from unlabeled surgical images. As a result, it allows for precise and efficient segmentation of vessels and instruments with only a small amount of labeled data. Specifically, we first construct a region adjacency graph (RAG) based on local semantic consistency in unlabeled surgical images and use it as a self-supervision signal for pseudo-mask segmentation. We then use the pseudo-mask to perform guided masked image modeling (GMIM) to learn representations that integrate structural information of intraoperative objectives more effectively. Our pretrained model, paired with various segmentation methods, can be applied to perform vessel and instrument segmentation accurately using limited labeled data for fine-tuning. We build an Intraoperative Vessel and Instrument Segmentation (IVIS) dataset, comprised of ~3 million unlabeled images and over 4,000 labeled images with manual vessel and instrument annotations to evaluate the effectiveness of our self-supervised pretraining method. We also evaluated the generalizability of our method to similar tasks using two public datasets. The results demonstrate that our approach outperforms the current state-of-the-art (SOTA) self-supervised representation learning methods in various surgical image segmentation tasks.

Background: Robotic hepatectomy (RH) is currently widely accepted and it is associated with some benefits when compared to open hepatectomy (OH). However, whether such benefits can still be achieved for patients with large hepatocellular carcinoma (HCC) remain unclear. This study aimed to evaluate the short-term and long-term outcomes of patients undergoing RH or OH. Methods: Perioperative and survival data from patients with large HCC who underwent RH or OH between January 2010 and December 2020 were collected from eight centres. Propensity score matching (PSM) was performed to minimise potential biases. Results: Using predefined inclusion criteria, 797 patients who underwent OH and 309 patients who underwent RH were enroled in this study. After PSM, 280 patients in the robotic group had shorter operative time (median 181 vs. 201 min, P <0.001), lower estimated blood loss (median 200 vs. 400 ml, P <0.001), and shorter postoperative length of stay (median 6 vs. 9 days, P <0.001) than 465 patients in the open group. There were no significant differences between the two groups in overall survival and recurrence-free survival. Cox analysis showed AFP greater than 400 ng/ml, tumour size greater than 10 cm, and microvascular invasion were independent risk factors for overall survival and recurrence-free survival. After PSM, subgroup analysis showed that patients with a huge HCC (diameter >10 cm) who underwent RH had significantly lower estimated blood loss (median 200.0 vs. 500.0 min, P <0.001), and shorter length of stay (median 7 vs. 10 days, P <0.001) than those who underwent OH. Conclusion: Safety and feasibility of RH and OH for patients with large HCC were comparable. RH resulted in similar long-term survival outcomes as OH.

The triglyceride-glucose (TyG) index and hypertension (HTN) are established risk factors of CVD. However, there is a dearth of studies investigating the synergistic influence of the elevated TyG index and HTN on CVD risk, as well as any potential interaction between these factors. For this investigation, we enlisted 88,384 individuals from the Kailuan Study who did not have a history of stroke, myocardial infarction, or cancer at baseline. Incidences of CVD between 2006 and 2021 were confirmed through a thorough review of medical records. Participants were categorized into 6 groups according to BP status(normal/elevated BP, stage 1 and stage 2) or the TyG index(low and elevated group), respectively. The Cox proportional hazard regression models were used to assess the association of BP status and TyG index with incident CVD. The multiplicative and additive interactions were also determined. Following a mean follow-up period of 13.66 ± 3.24 years, incidents of CVD, MI, and stroke were observed in 8,205, 1,728, and 6,705 individuals, respectively. The BP category and TyG index additively increased the risk of CVD, MI and stroke. There were significant interacting and joint effects of TyG index and BP status on CVD risk. Additionally, stratification analysis further confirmed that the relative contribution of hypertension to the CVD development decreased with deteriorating TyG index and that of TyG index was attenuated with increasing BP status. Our study demonstrated that a significant interaction between TyG index and BP status on the risk of CVD.

Background: Upper gastrointestinal bleeding (UGIB) is a prevalent etiology for hospital admissions on a global scale. However, the significance of UGIB as a warning sign of gastrointestinal (GI) cancer is frequently disregarded due to its uncommon and atypical symptoms. Methods: In the Kailuan study, participants diagnosed with UGIB were assigned as the case group and were randomly matched in a 1:4 ratio with a control group of comparable age and sex from 2006 to 2018 in Tangshan. The statistical analysis included a total of 1250 UGIB patients and 5000 individuals without UGIB. The impact of UGIB on cancer incidence was evaluated using a Cox proportional hazards model, enabling the investigation of both site -specific and time -dependent effects of UGIB on cancer incidence. Results: The mean age of the patients was 60.91 +/- 13.08 years. Over an average follow-up period of 8.92 years, there were 102 cases of cancer in the UGIB group and 210 cases in the non-UGIB group. The results of the Cox model analysis indicated that the strength of association between UGIB and cancer depends on specific cancer site. Excluding patients with follow-up periods of less than 1, 3, and 5 years weakened the associations between UGIB and GI cancer in sensitivity analysis. Conclusion: UGIB may serve as a sign of occult cancer, necessitating thorough evaluation of middle-aged and elderly patients presenting with this warning symptom to detect the possibility of missing a cancer diagnosis.

Background:With the rapid development of robotic surgery, especially for the abdominal surgery, robotic pancreatic surgery (RPS) has been applied increasingly around the world. However, evidence-based guidelines regarding its application, safety, and efficacy are still lacking. To harvest robust evidence and comprehensive clinical practice, this study aims to develop international guidelines on the use of RPS.Methods:World Health Organization (WHO) Handbook for Guideline Development, GRADE Grid method, Delphi vote, and the AGREE-II instrument were used to establish the Guideline Steering Group, Guideline Development Group, and Guideline Secretary Group, formulate 19 clinical questions, develop the recommendations, and draft the guidelines. Three online meetings were held on 04/12/2020, 30/11/2021, and 25/01/2022 to vote on the recommendations and get advice and suggestions from all involved experts. All the experts focusing on minimally invasive surgery from America, Europe and Oceania made great contributions to this consensus guideline.Results:After a systematic literature review 176 studies were included, 19 questions were addressed and 14 recommendations were developed through the expert assessment and comprehensive judgment of the quality and credibility of the evidence.Conclusions:The international RPS guidelines can guide current practice for surgeons, patients, medical societies, hospital administrators, and related social communities. Further randomized trials are required to determine the added value of RPS as compared to open and laparoscopic surgery.

BACKGROUND:Minimally invasive surgery is the optimal treatment for insulinoma. The present study aimed to compare short- and long-term outcomes of laparoscopic and robotic surgery for sporadic benign insulinoma.METHODS:A retrospective analysis of patients who underwent laparoscopic or robotic surgery for insulinoma at our center between September 2007 and December 2019 was conducted. The demographic, perioperative and postoperative follow-up results were compared between the laparoscopic and robotic groups.RESULTS:A total of 85 patients were enrolled, including 36 with laparoscopic approach and 49 with robotic approach. Enucleation was the preferred surgical procedure. Fifty-nine patients (69.4%) underwent enucleation; among them, 26 and 33 patients underwent laparoscopic and robotic surgery, respectively. Robotic enucleation had a lower conversion rate to laparotomy (0 vs. 19.2%, P = 0.013), shorter operative time (102.0 vs. 145.5 min, P = 0.008) and shorter postoperative hospital stay (6.0 vs. 8.5 d, P = 0.002) than laparoscopic enucleation. There were no differences between the groups in terms of intraoperative blood loss, the rates of postoperative pancreatic fistula and complications. After a median follow-up of 65 months, two patients in the laparoscopic group developed a functional recurrence and none of the patients in the robotic group had a recurrence.CONCLUSIONS:Robotic enucleation can reduce the conversion rate to laparotomy and shorten operative time, which might lead to a reduction in postoperative hospital stay.