Pancreaticojejunostomy is the most technically demanding and complication-prone component of pancreaticoduodenectomy. Despite nearly a century of continual refinement, postoperative pancreatic fistula (POPF) remains a major challenge. The incidence of pancreaticojejunostomy-related complications remains high, and clinically relevant grade B/C POPF can lead to severe infection, hemorrhage, or even death. Multiple factors influence its occurrence, among which the anastomotic technique is considered an independent risk factor. To reduce the incidence of POPF, pancreaticojejunostomy techniques have evolved along several dimensions, including operative approach, patterns of pancreaticjejunal alignment, and specific suturing strategies. These include end-to-end anastomosis, end-to-side invagination, duct-to-mucosa end-to-side anastomosis, and end-to-side intussusception techniques, each suited to particular clinical contexts, with no universally accepted optimal method to date. In recent years, Blumgart anastomosis—characterized by U-shaped sutures, adherence to the “mucosa-to-mucosa” healing principle, and favorable vascular preservation—has gained recognition for its stability and potential to reduce POPF, with favorable outcomes reported in multiple clinical studies and Meta-analyses. Beyond technique selection, individualized assessment is equally essential. Tension control, precise alignment, suture material choice, stent patency, and meticulous technical execution directly affect postoperative healing quality. The development of pancreaticojejunostomy has followed multiple parallel pathways, the application of laparoscopic and robotic-assisted pancreaticojejunostomy has gradually matured and gained acceptance, future progress will require establishing simplified, reproducible, minimally invasive, and standardized techniques applicable across diverse surgical settings, aiming to further reduce POPF incidence and improve postoperative recovery.
In recent years, the incidence of differentiated thyroid carcinoma (DTC) has shown a significant upward trend. In 2025, the American Thyroid Association updated management guidelines for adult patients with differentiated thyroid cancer, and reflect a more conservative and function-preserving philosophy in the field of surgical diagnosis and treatment. The new guidelines have broadened the indications for thyroid lobectomy, increasing the maximum tumor diameter from 1 cm to 2 cm for unilateral DTC without extrathyroidal extension or metastasis. Favor lobectomy as the preferred initial surgical approach for low-risk unilateral DTC with maximum tumor diameter 2-4 cm. For locoregional residual, clinically recurrent, or progressive disease, lymph node size is no longer the primary determinant for surgical decisions; instead, a comprehensive assessment is emphasized. The guidelines reinforce the role of intraoperative nerve monitoring in protecting the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve, and add a new recommendation for parathyroid autotransplantation. Thyroid-stimulating hormone suppression therapy shows a “de-escalation” trend, and it is explicitly stated with high-certainty that remnant ablation is not routinely recommended for low-risk DTC patients. For DTC during pregnancy, a more conservative strategy is adopted, suggesting that surgery can be safely postponed until after delivery for most patients.
Objective To assess the effectiveness of a two-stage deep-learning near-infrared autofluorescence (NIRAF) model for improving intraoperative parathyroid identification accuracy and to validate its utility in reducing false-positive rates and providing anatomical localization reference. Methods A total of 101 patients undergoing thyroidectomy at Fujian Medical University Union Hospital from January 2023 to December 2023 were prospectively enrolled. Under standard operating-room lighting at a fixed distance of 15 cm, a 785-nm laser NIR camera was used to acquire NIRAF images from fresh specimens’ post-resection, yielding 30,122 frames to construct the “Niraf24” dataset. The model consisted of a YOLOv8x detection network for fluorescence-signal localization and a Segment Anything Model v2 (SAM2) segmentation network for thyroid contour segmentation and background restoration. Performance was evaluated using sensitivity, precision, F1-score, false-positive rate, and intersection over union (IoU), and compared with conventional direct fluorescence reading. Results The two-stage model markedly reduced false positives: frame-level from 37.7% to 13.2% and specimen-level from 38.8% to 6.7% (both P<0.001). Precision increased from 62.3% to 86.8%, F1-score improved from 0.734 to 0.846, while sensitivity was maintained at 82.8%. The SAM2-derived thyroid contours achieved a mean IoU of (0.985±0.012), indicating highly consistent anatomical localization. The model remained robust in high-noise settings (brown adipose tissue, thermal coagulation eschar, diffuse high-fluorescence background, surgical dye contamination), effectively suppressing difficult false-positive signals. Without compromising sensitivity, the two-stage cascade approach markedly reduced false positives and improved overall performance compared to conventional interpretation methods, validating the task suitability of the “detection-first, classification-second” strategy and its feasibility for intraoperative application. Conclusion The YOLOv8-SAM2-based two-stage deep-learning cascade significantly enhances the specificity of NIRAF without compromising sensitivity, generating real-time, anatomically referenced visual information to support parathyroid preservation. This approach establishes a reproducible performance benchmark and offers a new paradigm for multicenter clinical validation and intraoperative intelligent decision-making, with the potential to reduce inadvertent parathyroidectomy and postoperative hypocalcemia.
Objective To explore the effects of perioperative nutritional management in colorectal cancer surgery under the concept of enhanced recovery after surgery (ERAS) based on ambulatory surgery model, and to provide reference and basis for its application. Methods A retrospective analysis was conducted on patients undergoing colorectal cancer radical surgery at the First Affiliated Hospital of China Medical University from October 1, 2023, to December 1, 2024. The study group received ambulatory laparoscopic colorectal cancer surgery and perioperative nutritional management based on the concept of ERAS, while the control group underwent traditional laparoscopic colorectal cancer surgery with conventional nutritional treatment. Results A total of 76 colorectal cancer patients were included in the study (38 in the study group and 38 in the control group). Before the intervention, there was no statistically significant difference in baseline data between the two groups (P>0.05), indicating comparability. After receiving the one-week intervention prior to surgery, the study group showed significant improvement in nutritional indicators compared to their pre-intervention levels(P<0.05). Nutritional indicators were compared between the two groups at preoperative day 1, postoperative day 1, day 7, and 1 month, with the study group outperforming the control group in all aspects (P<0.05). The study group also had a shorter time to first postoperative feeding, time to first postoperative flatus, and length of hospital stay compared to the control group (P<0.05), while there was no statistically significant difference in the incidence of postoperative complications between the two groups (P>0.05). Conclusion ERAS perioperative nutritional management in colorectal cancer surgery patients under the ambulatory surgery model has significant clinical effects, which can not only improve nutritional indicators, but also promote postoperative recovery, which is safe and feasible.
Objective To evaluate the impact of early percutaneous catheter drainage (PCD) on clinical outcomes in patients with severe acute pancreatitis (SAP) complicated by acute necrotic collection (ANC) and persistent organ failure (POF). Methods Clinical data of 310 consecutive patients with SAP combined with ANC and POF admitted to the Severe Acute Pancreatitis Center of the Eastern Theater General Hospital between January 2015 and December 2022 were retrospectively analyzed. According to whether PCD was performed within 4 weeks from disease onset, patients were divided into an early-intervention group (n=148) and a standard-treatment group (n=162). A 1∶1 propensity score matching (PSM) was used to balance baseline differences, with matching variables including Sequential Organ Failure Assessment (SOFA) score, intra-abdominal pressure (IAP), CT severity index (CTSI), use of sedatives, remifentanil-equivalent dose, and comorbidities. The primary outcome was 90-day mortality, and secondary outcomes were the incidence of major complications, proportion of open surgery, and length of hospital stay. Differences in clinical outcomes between groups were compared, and infectious characteristics and factors associated with early intervention were analyzed. Results After PSM, 85 patients were included in each group. The 90-day mortality did not differ significantly between the early-intervention and standard-treatment groups (24.71% vs.17.65%, P=0.260), and Kaplan-Meier survival analysis also showed no significant difference. The incidence of major complications was higher in the early-intervention group than in the standard-treatment group (72.94% vs.49.41%, P=0.002), with a significantly higher rate of infected pancreatic necrosis (IPN) (100.00% vs.43.53%, P<0.001) and a longer hospital stay [34.00 (22.00, 63.00) days vs.25.00 (15.00, 39.00) days, P=0.005]. Multivariate logistic regression analysis indicated that CTSI ≥8, total SOFA score ≥9, IAP>15 mmHg (1 mmHg=0.133 kPa), non-resolution of renal failure, and persistent disturbed consciousness were independent factors associated with receiving early intervention. Conclusion In patients with SAP complicated by ANC and POF, early PCD does not improve 90-day survival and is associated with a higher incidence of IPN and prolonged hospital stay. When determining the timing of intervention, clinicians should comprehensively evaluate SOFA score, IAP level, CTSI, and other parameters, and more cautiously balance the risks of intervention against potential benefits.
Objective To investigate the incidence and risk factors of peritoneal metastasis after curative-intent resection for perihilar cholangiocarcinoma (pCCA). Methods Clinical data of 75 pCCA cases undergoing curative-intent resection at the Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, from 2014-01 to 2023-06 were retrospectively analyzed. Clinicopathological characteristics were compared between the peritoneal-metastasis and non-peritoneal-metastasis groups. Cox proportional hazards regression was used to identify independent risk factors for postoperative peritoneal metastasis. Results The cumulative recurrence rates at 1, 3, and 5 years after surgery were 34.7%, 58.2%, and 74.9%, respectively. The peritoneum was the most common site of distant recurrence: 11/75 patients (14.7%) developed peritoneal metastasis, with a mean time to metastasis of (18.2±13.4) months. The median overall survival was 17.1 (11.8-47.8) months. Univariate Cox analysis indicated associations between Bismuth-Corlette classification, lymph-node metastasis, tumor differentiation and peritoneal metastasis (P<0.05). Multivariable analysis identified poor tumor differentiation as an independent risk factor (HR=4.022;95%CI: 1.110-14.566; P=0.034). Preoperative biliary drainage approach, tumor size, margin status, and vascular invasion were not significantly associated with peritoneal metastasis (P>0.05). Conclusion Poor tumor differentiation is an independent risk factor for peritoneal metastasis after curative-intent resection for pCCA. Peritoneal metastasis tends to occur at approximately 18 months postoperatively and portends a poor prognosis. Although preoperative percutaneous transhepatic biliary drainage (PTCD) was not an independent risk factor, its potential for tumor seeding warrants careful clinical consideration. For poorly differentiated pCCA, closer postoperative surveillance and individualized adjuvant strategies are warranted to reduce peritoneal metastasis and improve long-term survival.
Objective To investigate the clinical significance of prophylactic extrahepatic bile duct resection (EHBDR) in patients with T2 and T3 gallbladder cancer (GBC) and its impact on survival outcomes. Methods A retrospective analysis was performed on 69 patients with T2 and T3 GBC who underwent radical surgery at the Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital of Nanchang University, between March 2013 and March 2023. Patients were divided into the BDR (+) group and BDR (-) group according to whether EHBD resection was performed. Overall survival (OS) and disease-free survival (DFS) were compared between the two groups. Risk factors were identified using the Cox proportional hazards regression model, and subgroup analyses were further conducted. Student’s t test, Chi-square test, Fisher’s exact test, and Mann-Whitney U test were applied for group comparisons. Survival curves were generated using the Kaplan-Meier method, with P<0.05 considered statistically significant. Results In the overall cohort, no significant differences were observed in median OS (17.0 months vs.13.0 months, P=0.282) or median DFS (11.0 months vs.10.0 months, P=0.760) between the BDR (+) and BDR (-) groups. Multivariate analysis indicated that ≥2 positive lymph nodes and T3 stage were independent risk factors for OS (P=0.022, P=0.003). Subgroup analysis revealed that in patients with ≥2 positive lymph nodes or a positive lymph node ratio ≥0.2, the BDR (+) group had significantly better OS and DFS than the BDR (-) group (both P<0.05). Furthermore, in patients with perineural invasion, OS was significantly longer in the BDR (+) group compared with the BDR (-) group (P=0.026), while no significant difference was observed in DFS (P=0.187). Group comparisons showed that the BDR (+) group yielded a greater number of positive lymph nodes, a higher positive lymph node ratio, and a worse N stage (P<0.05), while postoperative complication rates were similar between the two groups (P=0.556). Conclusion EHBD resection in T2 and T3 GBC increases the number and ratio of positive lymph nodes harvested. For patients with ≥2 positive lymph nodes or a positive lymph node ratio ≥0.2, EHBD resection may improve survival outcomes.
Objective To investigate the risk factors associated with early recurrence (ER) after pancreaticoduodenectomy (PD) for distal cholangiocarcinoma (DCC). Methods A retrospective study was conducted based on the data of 60 patients pathologically confirmed with DCC following PD at Beijing Tsinghua Changgung Hospital between January 2015 and July 2023. Preoperative clinical data and contrast-enhanced upper abdominal multislice computed tomography (MSCT) images were collected. Differences in pancreatic invasion, lymph node metastasis, peripancreatic lymph node metastasis, and the presence of soft tissue around the superior mesenteric artery (SMA) were compared between the ER group (n=18) and the non-ER group (n=42). Chi-square test or Mann-Whitney U test was used for univariate analysis, followed by binary logistic regression to identify independent risk factors. Predictive performance was evaluated using the receiver operating characteristic (ROC) curve. Results Among the 60 patients with DCC, 18 (30.0%) cases experienced ER within 12 months postoperatively. The ER group showed significantly higher rates of pancreatic invasion (72.2%), lymph node metastasis (61.1%), peripancreatic lymph node metastasis (55.6%), and the presence of soft tissue around the SMA (55.6%) compared to the non-ER group (40.5%, 28.6%, 23.8%, and 16.7%, respectively; all P<0.05). Multivariate logistic regression identified the presence of soft tissue around the SMA as the only independent risk factor for ER (P=0.010, OR=5.878, 95%CI: 1.525-22.647). The area under the ROC curve (AUC) was 0.694, with a specificity of 83.8%. Conclusion The presence of soft tissue around the superior mesenteric artery is an independent imaging marker for predicting early recurrence after PD for DCC, providing a useful reference for preoperative risk stratification and treatment planning.
Hepatocellular carcinoma (HCC) is one of the most common malignant tumors, posing a serious threat to public health. Intermediate-stage HCC is characterized by its extensive coverage and significant heterogeneity, leading to considerable debate over staging optimization and personalized treatment. In recent years, advancements in local treatment methods, systemic therapy drugs, and breakthroughs in treatment strategies such as transformation therapy, neoadjuvant therapy, and postoperative adjuvant therapy have made multidisciplinary combined therapy a key direction for intermediate-stage HCC treatment. Staging of intermediate-stage HCC is crucial for developing personalized treatment plans and accurately assessing patient prognosis. Various staging systems for HCC have been proposed worldwide; however, there is ongoing controversy regarding the definition and applicability of intermediate-stage HCC. This has driven researchers to continuously optimize staging systems to improve prognostic prediction and therapeutic efficacy. In terms of treatment, traditional transarterial chemoembolization (TACE) has been the primary approach for intermediate-stage HCC, but not all patients benefit from it, and some develop resistance after multiple TACE sessions. Recently, significant progress has been made in the application of local treatments such as liver resection, hepatic arterial infusion chemotherapy (HAIC), and selective internal radiotherapy (SIRT), as well as targeted therapies and immunotherapies. The critical role of liver resection in the treatment of intermediate-stage HCC has gradually gained recognition; HAIC has shown promising efficacy in neoadjuvant therapy; SIRT has demonstrated superior results to traditional TACE in some clinical trials. Additionally, advancements in targeted therapies and immunotherapies offer new hope for patients with intermediate-stage HCC. Targeted drugs such as sorafenib and lenvatinib, and immune checkpoint inhibitors such as pembrolizumab and camrelizumab have shown good efficacy in prolonging patient survival. Combined treatment strategies, including the combination of targeted drugs and immunotherapy, as well as the combination of local and systemic treatments, have become research hotspots and have achieved positive results in several clinical trials. In the future, with the development of biomarkers and multi-omics molecular typing technologies, staging and treatment of intermediate-stage HCC will become more precise and personalized. The multidisciplinary team (MDT) approach helps integrate expertise from different disciplines to provide comprehensive and precise diagnostic and therapeutic plans for patients, improve treatment outcomes, and extend patient survival.
Neoadjuvant/induction therapy is a vital part of the systemic management of pancreatic cancer, and its efficacy directly affects the surgical implementation and survival benefits. Currently, assessment tools for evaluating the response to neoadjuvant/induction therapy in clinical practice are limited. In addition to imaging response and tumor regression grading, CA19-9 is commonly used as a biomarker to assess the effectiveness of neoadjuvant/induction therapy, with changes in its levels closely associated with patient prognosis. Studies have shown that resectable patients with preoperative CA19-9 levels >500 kU/L have postoperative survival outcomes comparable to those of borderline resectable patients, suggesting that these patients may benefit more from neoadjuvant therapy to improve prognosis. Additionally, the absolute value, reduction rate, and dynamic changes in CA19-9 levels are used to assess treatment efficacy and guide the timing of surgery. Several studies have explored the optimal cutoff values for CA19-9, generally finding that a reduction of >50% or a return to normal levels is significantly associated with better prognosis, though a definitive cutoff has not yet been established. CA19-9 also has a potential role in guiding the choice of adjuvant chemotherapy regimens following neoadjuvant therapy in pancreatic cancer. Some studies indicate that changes in CA19-9 levels after neoadjuvant therapy can help determine the need for adjuvant therapy postoperatively. Specifically, for patients with a poor response, adjuvant therapy after surgery can significantly extend survival, while for those with a favorable response, postoperative adjuvant therapy may not provide a clear benefit. The role of CA19-9 in neoadjuvant/induction therapy for pancreatic cancer is gaining recognition, with its utility as a key indicator for assessing tumor response and guiding treatment strategies. Further high-quality evidence-based studies are required to optimize its application.
Preventive stoma is often created after low anterior resection for rectal cancer to reduce the risk of severe complications such as anastomotic leakage. However, 6%-23% of preventive stomas ultimately become permanent, severely affecting patients’ physiological and psychological well-being. Major risk factors for non-reversal of preventive stoma include anastomotic leakage, anastomotic stricture, local recurrence, and distant metastasis, while neoadjuvant chemoradiotherapy and impaired anal function may also increase the risk. Additional potential factors include advanced age, male sex, positive circumferential resection margin, malnutrition, advanced tumor stage, and high American Society of Anesthesiologists (ASA) classification. Anastomotic leakage is considered the most important risk factor, as it is associated with stricture due to inflammation and may also influence patients’ decisions against reversal due to fear of reoperation. Local recurrence and distant metastasis can cause mechanical intestinal obstruction, constituting contraindications for stoma reversal. Interventions including intraoperative indocyanine green fluorescence angiography, transanal decompression tube placement, and early endoscopic vacuum-assisted therapy can reduce complication risk; anastomotic strictures can be managed with endoscopic balloon dilation, stent placement, or redo anastomosis. Measures to improve anal function include conformal sphincter preserving operation, pelvic floor rehabilitation, sacral nerve stimulation, and transanal irrigation. Identifying and intervening in high-risk factors, optimizing perioperative management, and emphasizing functional rehabilitation are key to increasing stoma reversal rates and improving patients’ quality of life.
Intraoperative misidentification or vascular damage of the parathyroid glands during thyroid surgery can lead to impaired parathyroid function and hypocalcemia. Therefore, the functional localization of parathyroid glands during thyroid (parathyroid) surgery is a key focus and challenge for thyroid specialists. Currently, the clinical application prospects of various optical imaging techniques for intraoperative localization, identification, and protection of parathyroid glands vary. Among them, near-infrared autogenous fluorescence and other label-free optical imaging techniques have advantages such as simplicity, efficiency, safety, real-time capability, and non-invasiveness, making them favored by surgeons. These techniques provide real-time protection for parathyroid glands and demonstrate significant advantages and application prospects in thyroid (parathyroid) surgery.
The incidence of papillary thyroid carcinoma continues to increase. Total thyroidectomy (TT) combined with bilateral central lymph node dissection (BCLND) remains the primary treatment modality for high-risk patients with recurrent disease. However, postoperative hypoparathyroidism (HP) is still a common complication. HP can be classified into transient and permanent types, with permanent HP leading to persistent hypocalcemia, abnormal bone metabolism, cardiovascular complications, and neuropsychological disorders, thereby severely impairing patients’ long-term quality of life. Parathyroid autotransplantation (PA), as both a preventive and remedial measure, has shown potential for reducing the incidence of permanent HP, although its preventive efficacy and indications remain controversial. In recent years, parathyroid protection strategies have evolved from the “1+X” principle to the “1+X+1” scheme, and further advanced to the precision-based “2+2” strategy, which involves preserving both superior parathyroid glands in situ while autotransplanting both inferior parathyroid glands. This approach not only ensures the thoroughness of central lymph node dissection but also enables the transplanted glands to undergo revascularization and functional recovery postoperatively, thereby significantly reducing the risk of permanent HP. Looking ahead, the integration of near-infrared autofluorescence imaging (NIR-AFI), intraoperative rapid parathyroid hormone monitoring (ioPTH), and artificial intelligence-assisted recognition may facilitate a shift toward precise and individualized parathyroid function preservation, ultimately achieving the dual goals of radical tumor resection and functional maintenance.
Ischemia following colorectal reconstruction is a major cause of severe complications such as anastomotic leakage, significantly impacting patient outcomes. This pathological condition disrupts the tissue healing process, with risk factors including vascular comorbidities (e.g., atherosclerosis and anatomical variations), surgical techniques (excessive tension or inadequate blood supply preservation), and ischemia-reperfusion injury. Prevention and management should be implemented throughout the perioperative period: preoperative vascular assessment through imaging, intraoperative refinement of anastomotic techniques combined with real-time perfusion monitoring using indocyanine green fluorescence imaging, and postoperative vigilance through clinical surveillance. Although pharmacological interventions to improve blood supply show promising experimental results, current clinical practice emphasizes optimized surgical techniques and comprehensive perioperative management. Enhanced strategies for prevention, early detection, and timely intervention of anastomotic ischemia are crucial for reducing postoperative complications.
Acute appendicitis (AA) is a common surgical acute abdomen. Compared with younger patients, elderly patients with AA present unique epidemiological characteristics and prognoses, including higher rates of mortality, perforation, and postoperative complications, as well as an increased risk of concurrent colorectal and appendiceal cancer, but lower diagnostic accuracy. Currently, two main international guidelines are available for the diagnosis and management of AA in the elderly: The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition) and the EAES rapid guideline: appendicitis in the elderly. Due to atypical clinical symptoms in elderly patients, the application of conventional clinical scoring systems such as the Alvarado score, Appendicitis Inflammatory Response (AIR) score, and Adult Appendicitis Score (AAS) is limited. The guidelines recommend computed tomography (CT) scan for elderly patients with an Alvarado score ≥5 to confirm the diagnosis; contrast-enhanced CT is particularly helpful in identifying appendiceal perforation. The core of the treatment strategy is to differentiate between uncomplicated and complicated appendicitis. For elderly patients with CT-confirmed uncomplicated appendicitis who are unwilling to undergo surgery and can accept the risk of recurrence, non-operative management with antibiotics is a feasible option, with a success rate of >70%. For complicated appendicitis with an abscess, percutaneous drainage combined with non-operative management is recommended. Laparoscopic appendectomy is recommended as the preferred surgical approach for elderly patients with AA owing to its advantages of minimal trauma, fewer complications, and shorter hospital stay. Furthermore, considering the significantly increased incidence of colorectal cancer in elderly patients with AA, the guidelines strongly recommend that all elderly patients with AA should undergo colonoscopic screening.
