Greated the limbs of small bowel has been a key link during Roux-en-Y gastric bypass （RYGB）. However, there is still no consensus on a proper length of small bowel exclusion. In current era of precision medicine, through accurately measuring the length of small bowel, appropriate length of small bowel exclusion may be individualized for optimizing surgical efficacies and lowering the occurrence of postoperative complications. Summarizing the effects of different small bowel exclusion lengths during gastric bypass on surgical outcomes, this review was intended to provide new rationales for future clinical practices and research designs.

Objective To evaluate the efficacies and risk factors of metabolic and bariatric surgery for obesity hypoventilation syndrome （OHS）. Methods Between January 2018 and June 2022, retrospective review was conducted for 957 OHS patients undergoing metabolic and bariatric surgery.Clinical data of baseline profiles, arterial blood gas analysis, sleep study and anthropometric parameters were collected retrospectively for preoperative assessments and 2-year postoperative follow-ups. Perioperative changes of body mass index （BMI）, arterial blood gas, sleep study and anthropometric parameters were compared. The relationship between OHS resolution and variables was examined. Multivariate analysis was utilized for identifying the risk factors for OHS resolution. Results Among them, 105 were preoperatively diagnosed as OHS [BMI （40.1±7.2） kg/m², partial pressure of carbon dioxide in arterial blood（PaCO₂）（48.5±4.0） mmHg].At 2-year postoperative follow-up 89 cases （84.8%） fulfilled the criteria for OHS resolution. BMI dropped to（28.9±5.4） kg/m²（P<0.001,vs.BMI in preoperation period） and PaCO₂ declined to （44.4±4.8） mmHg （P<0.001, vs. PaCO₂ in preoperation period）. Percentage of total weight loss （%TWL） was lower in non-resolution group than that in OHS resolution group[（25.8±7.9）% vs. （27.7±8.9）%,P=0.017].Multivariate analysis revealed that preoperative arterial blood pH<7.35（OR=3.227,95% CI：1.002-10.392,P=0.049） and preoperative hypertension（OR=5.018,95%CI：1.476-17.064,P=0.010） were independent risk factors affecting OHS resolution after metabolic and bariatric surgery. Conclusion Metabolic and bariatric surgery is efficacious for OHS. And resolution of OHS depends upon achieving a certain level of ∆BMI and %TWL. Preoperative decompensation may be an independent risk factor for postoperative non-resolution of OHS.

Objective To establish and validate a nomogram prediction model based upon Objective factors for predicting gangrenous/perforated appendicitis （GPA） in children with acute appendicitis （AA）. Methods Between January 2010 and September 2024, the relevant clinical data were retrospectively reviewed for 350 AA children. And patients admitted between January 2010 and December 2019 were allocated into study group （n=225） while those admitted between January 2020 and September 2024 were selected as validation group（n=125）. Appendectomy was performed after a definite diagnosis. They were assigned into two groups of non-gangrenous/perforated appendicitis （N-GPA） and gangrenous/perforated appendicitis （GPA） according to the postoperative results of pathological examination. A comparison was made between two groups. And independent risk factors for GPA were identified through LASSO regression and multivariate Logistic regression analysis. Then these factors were utilized for constructing a nomogram prediction model. Internal validation of nomogram model was conducted with validation group. The area under the receiver operating characteristic curve （AUC） and Hosmer-Lemeshow （H-L） goodness-of-fit test were applied for assessing the model's discrimination and calibration. Results Preoperative computed tomography （CT） findings of fecalith within appendiceal lumen, leukocyte count, duration of symptoms, body temperature and appendiceal diameter as measured by preoperative CT were identified as independent risk factors for GPA in AA children （P< 0.05）. AUC for nomogram prediction model was 0.896 （95%CI： 0.848-0.943） in study group and 0.899 （95%CI： 0.825-0.972） in validation group, indicating an excellent discriminatory power. H-L test results were P=0.459 （χ2=6.72） for study group and P=0.272 （χ2=9.91） for validation group, indicating that nomogram model had a decent predictive accuracy. Conclusion The nomogram prediction model developed here demonstrates high accuracy and it may be readily applied for early identification and risk prediction of GPA in AA children.

Spontaneous rupture of hepatocellular carcinoma（HCC） is a life-threatening acute complication in HCC patients,clinically manifested as spontaneous tumor rupture and intra-abdominal hemorrhage.Although classified in T₄ by the TNM staging system,targeted treatment strategies can significantly improve the survival prognosis of spontaneous rupture of HCC.This review comprehensively analyzed the epidemiological characteristics,risk factors,pathophysiological mechanisms,and the efficacy differences of various treatment modalities for spontaneous rupture of HCC.It focused on the timing of surgery,perioperative management strategies,and the application of postoperative prognostic prediction models,aiming to provide evidence-based guidance for clinical treatment.Additionally,by integrating recent research advancements,we discussed the importance of redefining the staging of spontaneous rupture of HCC to optimize diagnostic and therapeutic strategies,thereby improving the survival and quality of life.The review also incorporated the previous experience of our center to present the clinical experience in managing spontaneous rupture of HCC at Liver Center,Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology.

Objective This study aims to assess the effectiveness of a modified Chen's pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy （LPD）. Methods A retrospective analysis was conducted on the clinical data of 121 patients who underwent LPD at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology between January 2023 and October 2024. The patients were divided into two groups： traditional surgery group （63 patients） and modified Chen's pancreaticojejunostomy （modified surgery group） （58 patients）. Gender, age, body mass index （BMI）, operation time, pancreatojejunostomy time, intraoperative blood loss, postoperative hospital stay, and the incidence of postoperative complications like pancreatic fistula, abdominal infection, intra-abdominal bleeding, gastrointestinal dysfunction, and mortality were compared between groups. Additionally, moderate-to-high risk patients for pancreatic fistula were identified using the alternative pancreatic fistula risk score system （a-FRS）. The risk of pancreatic fistulas between groups was compared. Quantitative data adhering to a normal distribution were expressed as $\bar{x}±s$ ; otherwise, they were expressed as quartiles [M（Q₁,Q₃）]. Count data were presented as the number of instances. Results Patients in the modified surgery group showed significantly shorter operation time（311.8±55.0 min vs. 357.5±84.5 min,P=0.001）and pancreatojejunostomy time [15.5 （13.8,18.0） min vs. 26.0 （23.0,29.0） min,P<0.001] compared to the traditional surgery group. The incidence of clinically relevant postoperative pancreatic fistula was also significantly lower in the modified surgery group than in the traditional surgery group [3.4% （2/58） vs. 15.9% （10/63）, P=0.022]. There were no significant differences between the two groups in the age, gender, BMI, proportion of patients at moderate-to-high risk for pancreatic fistula, intraoperative blood loss, postoperative hospital stay, rates of abdominal infection, intra-abdominal bleeding, and gastrointestinal dysfunction （P>0.05）. There were no perioperative deaths in both groups. Among the 62 patients at a moderate-to-high risk for pancreatic fistula using the a-FRS model （34 in the traditional surgery group and 28 in the modified surgery group）, those in the modified surgery group still showed significantly shorter operation and pancreatojejunostomy times （P<0.05） and a lower incidence of postoperative pancreatic fistula （P=0.036）. Conclusion The modified Chen's pancreaticojejunostomy simplifies the procedure, decreases the duration of pancreatojejunostomy, and reduces the occurrence of pancreatic fistulas. This technique is effective for patients assessed as having a moderate-to-high risk of developing pancreatic fistulas.

Gastric cancer （GC） is one of the most prevalent malignant neoplasms in the world. Due to mild and often unnoticed early symptoms and a low screening rate, most patients are diagnosed at a locally advanced or a late stage with poor outcomes. In recent years, immunotherapy has made significant headways in the treatment of GC, particularly for those with unresectable tumors and recurrent metastases. It has emerged as a valuable additional option for patients after surgery, chemoradiotherapy and targeted therapy. With a deeper understanding of tumor immunology, theoretical mechanisms of immunotherapy are continuously refined. A series of clinical studies on immune checkpoint inhibitors of programmed death protein-1 and programmed death protein ligand-1 have demonstrated promising efficacy for GC. And immunotherapy is gradually transforming the therapeutic paradigm of GC. This review summarized the latest researches of immunotherapy for GC through elucidating the mechanisms of immunotherapy, examining the utility of programmed death protein ligand-1 protein expression assay in identifying potential beneficiaries of immunotherapy and evaluating the applications of immunotherapy for advanced and progressive GC.

Objective To explore the influencing factors for perioperative complications of right laparoscopic hemicolectomy and construct a risk model of column graph.Methods From October 2019 to June 2023, the relevant clinical data were retrospectively reviewed for 223 patients undergoing right laparoscopic hemicolectomy. They were divided into two groups of complication （n=42） and non-complication （n=181） according to whether or not complications occurred in perioperative period. Multivariate Logistic regression was utilized for examining the influencing factors for perioperative complications. R4.3.2 software was utilized for constructing a prediction model of perioperative complications. Receiver operating characteristic （ROC） curve was employed for measuring the predictive value of nomogram and Hosmer-Lemeshow goodness of fit calibration curve for evaluating the fitting degree of nomogram. Decision curve analysis （DCA） was employed for examining the clinical utility of predictive model.Results Among them, 42 patients had complications during perioperative period. Multivariate Logistic regression analysis indicated that diabetes mellitus （DM）, operative duration >3 h, low tumor differentiation, external abdominal anastomosis and APACHE-Ⅱ score ≥14 were independent risk factors for perioperative complications （P<0.05）. The prediction probability of perioperative complications could be calculated by constructing the visualization risk prediction diagram of risk factors. DCA curve of nomogram prediction model was plotted. When prediction probability threshold was between 0 and 0.6, net return rate of nomogram model for perioperative complications was higher. The area under ROC curve was 0.941（95%CI： 0.893-0.988） with a sensitivity of 87.46% and a specificity of 81.48%. It suggested that the nomogram prediction model had a decent discriminant capability. Hosmer-Lemeshow goodness of fit test χ²=5.236, P=0.732, actual curve of calibration curve approximated an ideal curve. Predicted probability accorded well with actual probability.Conclusion Concurrent DM, operative duration >3 h, low tumor differentiation, external abdominal anastomosis and APACHE-Ⅱ score ≥14 are independent risk factors for perioperative complications of laparoscopic right hemicolectomy. The prediction model based upon the above nomogram is both accurate and well-differentiated. Clinical practicability is excellent.

Objective To explore the clinical value of Apfel score in predicting postoperative nausea and vomiting（PONV） after laparoscopic sleeve gastrectomy（LSG）. Methods Between January 2022 and March 2023, the relevant clinical data were collected from 80 morbidly obese patients undergoing LSG. They were assessed by the Apfel scoring system, including such factors as gender, smoking history, history of motion sickness or PONV and postoperative opioid use. PONV occurrences within 72 h post-LSG were assessed by visual analogue scale（VAS）, verbal descriptor scale（VDS） and PONV frequency score. Spearman's correlation was utilized for examining the relationship between Apfel and VAS/VDS/PONV frequency scores. Receiver operating characteristic（ROC） curve was plotted for evaluating the predictive value of Apfel score for PONV occurrence/severity and the area under the curve（AUC） calculated. Results Mean Apfel score was （1.76±0.96）. Within 72 h post-LSG, mean VAS/VDS/PONV frequency scores were （4.19±2.96）, （1.09±0.77） and （2.68±1.81）.Spearman's correlation coefficients between Apfel and VAS/VDS/PONV frequency scores were 0.3639, 0.3563 and 0.2985, all denoting a positive correlation （P<0.05）. Apfel score had the highest predictive value for VDS in predicting the occurrence of PONV （AUC=0.741,P<0.05） while it offered the best predictive value for VAS in predicting the severity of PONV （AUC=0.706, P<0.05）. Conclusion Apfel score is correlated with PONV score after LSG. However, its predictive value for VAS/VDS/PONV frequency score varies when assessing the occurrence/severity of PONV. Clinically Apfel score should be utilized with a consideration of specific predictive goals.

Pancreaticojejunostomy is the preferred method of pancreatic digestive tract reconstruction,serving as the most critical step in pancreaticoduodenectomy.It largely determines the occurrence of postoperative pancreatic fistula and other related complications.With the rapid development of pancreatic surgery,the method of pancreaticojejunostomy has undergone different improvements.This article reviewed the characteristics and development trends of common pancreaticojejunostomy in recent years, and proposed a modified pancreaticojejunostomy, namely parallel pancreaticojejunostomy,emphasizing the key points and advantages of the operation, and providing a certain reference for colleagues to perform pancreaticojejunostomy.

此文回顾性分析了1例63岁男性直肠神经内分泌癌病人的临床特点及治疗过程,以提高对此类疾病的认识。该例病人入院完善CT检查及结肠镜检查之后行腹腔镜直肠癌根治+回肠造口术,术后出现吻合口漏、右侧阴囊及右侧腹股沟区出现坏死性筋膜炎,行右侧腹股沟、右侧阴囊坏死性筋膜炎扩创术+封闭式创面负压吸引术,右上腹肋缘下出现坏死性筋膜炎,局部麻醉下行间断切开引流,给予亚胺培南西司他丁抗感染治疗,坏死性筋膜炎区域肉芽组织新鲜后缝合切口出院。病人术后因颈椎转移瘤压迫脊髓引起相关症状,生存2.5个月后死亡。直肠神经内分泌癌是一种罕见的直肠恶性肿瘤,侵袭性强、易发生转移、预后差。

Objective This study was intended to summarize the clinical characteristics of Crohn's disease （CD） complicated with intestinal perforation and explore the efficacy of surgery.Methods From January 2000 to October 2022, 25 cases of CD complicated with intestinal perforation at Affiliated Union Hospital were retrospectively reviewed. Clinical characteristics, surgical approaches and clinical follow-up data were summarized.Results Among them, males dominated （84%） with a diagnostic age of 17 to 40 years （80%）. The major site of perforation was ileum （72%） and nature of lesions largely transmural （80%）. Surgical approaches included laparoscopic-assisted bowel resection （52%） and multiple ileostomies （76.9%）. The postoperative complication rate was 28% and infections dominated. Both preoperative and postoperative patients were prone to anemia and hypoproteinemia. During follow-ups, there were recurrence （n=12, 48%） and death （n=1）.Conclusion CD complicated with intestinal perforation is more common in males and perforation occurs predominantly in ileum. Emergency surgery is recommended for all patients upon admission. Timely identification of etiology, optimal perioperative management and appropriate selection of surgical procedures may lower the incidence of postoperative complications and recurrence.

An Objective measurement of surgical outcome quality has long been a daunting challenge for researchers. Technical skill of a surgeon is a crucial influencing factor of clinical outcomes. Assessing surgical skills is not only vital for education, training and professional growth of surgeons but also has profound implications for enhancing surgical quality, ensuring patient safety and advancing medicine. Gradually the assessment of surgical skills has evolved from an initial experiential evaluation model by panels of surgical experts to a data-based Objective assessment tool model, including global rating scales, procedure-specific assessment tools and error-based evaluation instruments. In recent years, with a growing integration of medical and engineering fields, some automated assessment tools equipped with automatic recognition capabilities have started to emerge. This article summarized the development, current status, advantages and limitations of different types of laparoscopic skill assessment tools in conjunctions with a literature review.

双肝外胆管畸形在临床上极为罕见,此文报道了1例由2条独立的肝外胆管相互汇合后进入十二指肠且无异位引流的双肝外胆管畸形病例,探讨双肝外胆管畸形的临床特征和超声声像图特点,并与手术、T管造影进行对照,结合相关文献进行总结分析。双肝外胆管畸形是一种少见的先天性胆道畸形,临床表现不典型,极易漏诊误诊,彩色多普勒超声等影像学检查在双肝外胆管畸形诊断方面具有重要意义。

With rapid advances of metabolic and bariatric surgery（MBS）, decision-making process is becoming more and more complex regarding its application in patients with obesity and specific comorbidities. Efficacy and safety of MBS in high-risk cohorts, including those with cirrhosis, renal insufficiency and across an age spectrum from elders to adolescents, has remained controversial subjects. An expert consensus on optimal surgical approaches for these individuals has yet to be established, necessitating further investigations and validations. This paper focused upon the intricacies of conducting MBS in patients with unique metabolic and bariatric profiles.The authors critically assessed the risks and benefits associated with these procedures and offered a comprehensive overview of clinical considerations. There were four major issues of special weight considerations, age-related factors, challenging comorbidities and transitional procedures. The Objective was to contribute valuable insights to the existing body of knowledge and aid clinicians in making informed decisions when contemplating MBS for patients with special needs.

Neoadjuvant immunotherapy has become an effective modality for enhancing the therapeutic efficacy of locally advanced gastric cancer （LAGC）. In modern era of mini-invasive surgery, favorable tumor response, treatment-related adverse events and potential impact on perioperative tissues from neoadjuvant immunotherapy are correlated closely with perioperative safety and long-term survival. Current evidence suggests that mini-invasive gastrectomy after neoadjuvant immunotherapy is both safe and feasible with comparable short-term outcomes and long-term survival despite intraoperative difficulties. On this basis, clinical cooperation should be actively promoted for addressing such key issues as timing of surgery after neoadjuvant immunotherapy, individualized lymph node dissection and function-preserving mini-invasive gastrectomy to standardize and expand the indications for mini-invasive gastrectomy after neoadjuvant immunotherapy for LAGC.

Gastric cancer （GC） is a common malignant tumor with a high incidence and elevated mortality rate. In recent years, PD-1/PD-L1 immune checkpoint inhibitors have rapidly become one of common treatments for GC due to their superior efficacy. Notably, recent studies have highlighted the critical role of tumor microenvironment in cancer progression. Among various cell types present in the tumor microenvironment, tumor-associated macrophages （TAMs） are the most abundant. These macrophages can express PD-1 and interact with PD-L1 on the surface of cancer cells. Therefore TAMs may influence the therapeutic effectiveness of PD-1/PD-L1 immune checkpoint inhibitors for GC. However, there are few current researches on this topic and the underlying mechanisms have remain elsuive. This review summarized the latest researches to provide more treatment options for GC patients.

Objective To explore the effect of preoperative biliary drainage on perioperative period （during hospitalization or 30 days post-operation） in patients with pancreatic head or periampullary carcinoma undergoing open pancreaticoduodenectomy.Methods From October 1, 2019 to October 1, 2022, retrospective analysis was performed for 73 patients of pancreatic head or periampullae carcinoma undergoing pancreaticoduodenectomy including biliary drainage （n=33） and without biliary drainage （n=40）. The changes of total bilirubin（TBIL）, alanine transaminase （ALT）, glutamic oxalacetic transaminase （GOT）, albumin and creatinine before yellowing （at admission） and after yellowing （pre-operation） were compared for evaluating the effect of biliary drainage biliary drainage group. Then statistical differences were examined in postoperative complications between biliary drainage and without biliary drainage groups. Statistical software SPSS21 was used for statistical processings.Results The preoperative levels of TBIL, albumin, ALT and AST declined as compared with admission （P<0.05）. The preoperative level of creatinine had no significant change as compared with admission （P>0.05）. Biliary drainage group was more prone to have a higher incidence of tertiary complications （P<0.05）, a longer time from admission to surgery （P<0.05） and a longer total hospitalization stay （P<0.05）. No significant differences existed in operative duration, intraoperative volume of blood loss, intraoperative unit of blood transfusion, bile leakage, gastroparesis, peritoneal infection, pancreatic leakage, hemorrhage, wound infection, mortality, incidence of complications or postoperative hospitalization stay （P>0.05）.Conclusion Preoperative biliary drainage may lower the level of bilirubin in patients with severe jaundice caused by periampullary carcinoma, improve liver function and have no effect upon the level of creatinine. Preoperative biliary drainage may cause a decline of serum albumin. Preoperative biliary drainage may not reduce operative duration, volume of intraoperative blood loss and unit of intraoperative blood transfusion. It can not reduce the incidence of biliary leakage, gastroparesis, abdominal infection, pancreatic leakage, postoperative bleeding, wound infection, death, other complications or total complications. Length of postoperative hospitalization stay is not shortened. There are higher rates of tertiary and higher complications, longer overall hospitalization stay and extended time from admission to surgery. Patients with severe jaundice （TBIL ≥250 μmol/L） caused by pancreatic head or periampullary carcinoma should not be routinely treated preoperatively with biliary drainage.

2023年10月24日武汉大学中南医院肝胆胰外科收治1例71岁女性罕见胆囊肉瘤样癌合并Ⅰ型神经纤维瘤、胃肠间质瘤病人,该例病人因“上腹痛4 d,加重半天”就诊。腹部增强CT示,胆囊壁不均匀增厚并腔内软组织影并周围渗出、积液并脓肿形成,胆囊癌可能;左侧腹腔见类圆形软组织密度影。病人既往诊断Ⅰ型神经纤维瘤。于2023年10月31日行胆囊切除术+小肠部分切除术。术后病理及免疫组织化学诊断为胆囊肉瘤样癌、胃肠间质瘤。病人术后行放化疗及靶向治疗,2024年6月8日因肝转移瘤-结肠瘘合并腹腔感染死亡。胆囊肉瘤样癌临床罕见,与其他类型胆囊癌鉴别困难,需综合病理和免疫组织化学才能明确诊断,尚未有确切的诊疗指南,预后不佳。Ⅰ型神经纤维瘤老年病人建议常规筛查消化道肿瘤。

The most common symptom of extrahepatic cholangiocarcinoma is jaundice. Due to a lack of early special symptoms, most patients become inoperable at the time of an initial diagnosis. The prognosis of patients with advanced or unresectable extrahepatic cholangiocarcinoma is generally poor owing to ineffective palliative therapy. Stenting for bile duct drainage has been a standard procedure of relieving symptoms and improving quality-of-life. However, no significant improvement of median survival time is noted. Photodynamic therapy is a combination of photosensitizer and laser light. In conjunctions with biliary stenting, surgery and chemoimmunotherapy, targeted accumulation of photosensitizer in tumor tissues and accurate activation by laser light may further boost the curative efficacies. With bright application prospects, it may be employed as an effective local therapy for unresectable extrahepatic cholangiocarcinoma.

Objective To explore the effect of neoadjuvant chemotherapy or immunochemotherapy on perioperative safety and efficacy in patients with advanced gastric cancer （GC） and adenocarcinoma of gastroesophageal junction.Methods From January 2021 to January 2024, retrospective review was performed for the relevant clinical data of 88 patients undergoing neoadjuvant therapy and surgery. Individuals on preoperative radiotherapy were excluded. Based upon different preoperative medication regimens, they were assigned into two groups of neoadjuvant chemotherapy alone （n=55） and preoperative immunochemotherapy （n=33）. No statistically significant inter-group differences existed in clinicopathological characteristics. The major outcome measures included operative duration, volume of blood loss, R0 resection rate, dissected lymph node number, time to an initial anal exhaust, length of postoperative hospitalization stay, total hospitalization expense and the incidence of postoperative overall and severe complications. Secondary outcome measure was tumor regression grade （TRG） of primary gastric lesion.Results No statistically significant inter-group differences existed in operative duration, volume of blood loss, R0 resection rate, number of lymph node dissections, time to an initial anal exhaust, total hospitalization expense or length of postoperative stay. The overall incidence of postoperative complications was slightly higher in combination immunotherapy group. There was no statistically significant difference （P>0.05）. Both groups exhibited remarkably low rates of severe complications. There was no statistically significant difference （P>0.05）. As compared with neoadjuvant chemotherapy alone group, preoperative immunochemotherapy group had a significantly higher proportion of complete/partial remission （P<0.05）. And the proportion of TRG grade 0/1 was significantly higher in preoperative immunochemotherapy group （P<0.05）.Conclusion Preoperative immunochemotherapy does not elevate perioperative surgical risks and may achieve better short-term outcomes. Further studies are required for evaluating possible long-term outcomes.

The global incidence and mortality of primary liver cancer （PLC） are relatively high. Although 5-year survival rate of patients with early detection and curative treatment surpasses 60%, postoperative stress, complications and tumor recurrence seriously affect the quality-of-life and survival of patients post-operation. Due to their functions of regulating lipid metabolism, lowering oxidative stress and maintaining intestinal health, ω-3 PUFAs were not only extensively applied as a commercial food supplement for preventing the development of liver cancer but also as an active component of parenteral nutrition fat emulsion in postoperative patients. Existing studies have shown that postoperative application of omega-3 PUFAs in PLC patients could blunt inflammatory response, protect liver function, reduce the occurrence of infection and thus shorten the length of hospital stay. In patients at a high risk for recurrence, long-term use of omega-3 PUFAs or in combination with adjuvant therapy offered beneficial effects of mproved adjuvant therapy and prevention of adverse toxic effects. However, another study contradicted the previous findings. Thus the mechanism of action of omega-3 PUFAs is so complex that many regulatory links remain to be further elucidated. Its impact on clinical parameters of postoperative PLC patients should be confirmed with a large amount of data.

Objective Pancreatic Squamous Cell Carcinoma （PSCC） has a poor prognosis and it lacks individualized prognostic tools. This study aimed to construct prognostic nomograms for PSCC patients based upon machine learning and using large-scale real-world data from the database of SEER, provide precise and individualized prognostic assessments and offer valuable references for clinical decision-making.Methods From 2000 to 2019, the relevant clinical data of 367 pathologically diagnosed PSCC patients were extracted from the database of SEER. They were randomized by a ratio of 7∶3 into training （n=256） and verification （n=111） sets. Multivariate Cox proportional hazard model, LASSO regression and random survival forest model were utilized for identifying independent prognostic factors for patient survival. These factors were utilized for constructing nomograms for predicting cancer specific survival （CSS） and total survival （OS） at Month 3/6. Subsequently, the models were internally and externally validated in training and validation sets by concordance index （C-index）, receiver operating characteristic （ROC） and calibration curves for assessing their accuracy and predictive capacity.Results The median follow-up period in training and verification sets were 3（1,7） and 2（1,8） month. Baseline profiles were comparable between two groups （all P>0.05）. Multivariate Cox proportional hazard model analysis indicated that tumor size, M/N stage, surgery and chemotherapy were independent influencing factors for OS/CSS. LASSO regression analysis revealed that M stage, surgery and chemotherapy were associated with OS/CSS. For OS, top four scoring variables for via random survival forest model were chemotherapy, M stage, surgery and age; For CSS, chemotherapy, M stage, surgery and tumor size. Nomograms for predicting OS/CSS at Month 3/6 were developed based upon these independent prognostic factors. Validation results showed that C-index for OS in training and verification sets were 0.753（95%CI：0.720-0.790） and 0.723（95%CI：0.660-0.780） and for CSS 0.749（95%CI：0.720-0.780） and 0.721（95%CI：0.660-0.780）. ROC curve analysis indicated that AUC values for OS in training and verification sets were 79.8% and 75.9% at Month 3, 78.9% and 76.8% at Month 6 and 78.7% and 77.5% at Month 12; for CSS, 79.3% and 76.3% at Month 3, 78.6% and 76.9% at Month 6 and 77.4% and 78.4% at Month 12 respectively. Calibration curve analysis demonstrated a decent agreement between predicted and actual OS/CSS. Both were closely situated near ideal 45° reference line, demonstrating a high consistency.Conclusion Age, M stage, tumor size, surgery and chemotherapy are independent prognostic factors for PSCC patients. And the above constructed nomogram prediction models exhibit favorable predictive value and facilitate personalized therapeutics for PSCC patients in clinical practices.

With the continuous advancement of functional anatomy of the liver and the widespread use of fluorescence laparoscopic equipment, indocyanine green fluorescence imaging-assisted anatomical liver resection has gradually become a main stream for treating liver tumors. It effectively compensates for the difficulty of accurately marking deep liver segment boundaries in traditional liver resection. This article, combining domestic and international research progress, reviewed the application of indocyanine green fluorescence imaging for liver segment identification in anatomical liver resection. It also discussed the advantages and limitations of different staining techniques and provided an outlook on the future development.

Intrahepatic cholangiocarcinoma（ICC） is the most common biliary malignancy, serving as the top 2 primary hepatocellular carcinoma only secondary to hepatocellular carcinoma.Its onset is insidious and progresses rapidly,and surgical resection is the only curable approach.However,ICC is featured by a high degree of malignancy, and difficulty in the early diagnosis, and many patients are found in the middle and advanced stages that cannot be surgically treated. Therefore,the long-term survival of ICC is low,showing a poor prognosis,and the 5-year survival of advanced ICC of only 5%-10%.In recent years,systemic chemotherapy,hepatic arterial perfusion chemotherapy,and hepatic arterial chemoembolization have shown good results in ICC treatment.The advent of targeted and immunotherapy has brought a new hope for unresectable ICC.This paper reviewed the research progress of chemotherapy,local therapy,radiotherapy,targeted therapy and immunotherapy in the treatment of advanced ICC,so as to provide new ideas for ICC treatment.

Restorative proctocolectomy with ileal pouch-anal anastomosis （IPAA） is preferred for patients with medically refractory ulcerative colitis （UC） and familial adenomatous polyposis （FAP）. While many reports have discussed postoperative surgical and inflammatory complications of pouch, functional pouch disorders are poorly understood. Two complicating factors are a great variability of defining functional outcomes after IPAA and a lack of standardization for reporting symptoms. Normal pouch function has yet to be adequately defined. The underlying etiologies for poor functional outcomes are quite diverse, such as pelvic sepsis, pouchitis, anastomotic complications and pouch volvulus, etc. However, some patients manifest poor pouch function even without such complications. It is possibly due to non-optimal pouch physiology or such specific patient factors as age, gender, body mass index （BMI） and dietary habits. Therefore it is imperative to explore the normal physiological function of pouch and better manage the functional complications to enhance the postoperative quality-of-life.

Objective To explore the values of fibrinogen （FIB） and interleukin-6 （IL-6） in assessing the severity of acute cholecystitis （AC）.Methods From October 2021 to October 2023, 165 AC patients within 72 hours of onset were recruited. According to the severity of AC, they were assigned into two groups of mild cholecystitis （n=78） and moderate/severe cholecystitis （n=87）. The levels of FIB and IL-6 were detected and receiver operating characteristic （ROC） curves plotted for assessing the value of FIB/IL-6 for the severity of AC.Results The levels of FIB and IL-6 were significantly higher in moderate/severe cholecystitis group than those in mild cholecystitis group. And the inter-group difference was statistically significant （P<0.05）. ROC curve indicated that area under the curve （AUC） predicted by FIB was 0.760. The optimal diagnostic point was 3.455 g/L with a sensitivity of 85.1% and a specificity of 55.1%. And AUC predicted by IL-6 was 0.752. The optimal diagnostic point was 83.365 pg/ml with a sensitivity of 48.3% and a specificity of 100%. AUC of FIB plus IL-6 in predicting the severity of AC was 0.845. It was significantly higher than AUC predicted by each alone. The sensitivity was 67.8% and the specificity 84.6%.Conclusion The levels of FIB and IL-6 spike markedly in moderate/severe cholecystitis. Both parameters have higher values in judging the severity of AC. And a combination of both is even better.

Objective To explore the potential categories and influencing factors of grazing behavior among patients undergoing metabolic and bariatric surgery （MBS）. Methods From January to June 2024, MBS outpatients were selected by convenience sampling. Baseline Demographic Information Questionnaire, Chinese version of Repetitive Eating Questionnaire[Rep（eat）-Q], 21-item Three-Factor Eating Questionnaire（TFEQ-R21） and Chinese Version of Depression Anxiety and Stress Scale-21（DASS-21） were administered. One-way ANOVA and Logistic regression analyses were performed for identifying the factors associated with potential categories of grazing behavior. Results Among a total of 236 questionnaires, 230 valid ones were returned with an effective recovery rate of 97.5%. Grazing behavior occured in 178 patients （77.4%）. Grazing behaviors among MBS patients were divided into 3 latent classes of "low risk of grazing behavior-regular"（48.3%）,"medium risk of grazing behavior-compulsive"（37.4%） and "high risk of grazing behavior-repetitive"（14.3%）. As compared with "medium risk of grazing behavior-compulsive", patients with postoperative time <12 month, postoperative time 12-<24 month and lower scores of uncontrolled eating were more likely to be classified as "low risk of grazing behavior-regular"（OR=0.256,P=0.003;OR=0.311,P=0.020; OR=1.195,P<0.001）;As compared with "high risk of grazing behavior-repetitive", patients with no-depression, restricted eating and uncontrolled eating were more likely to be classified as "low risk of grazing behavior-regular"（OR=0.184,P<0.001;OR=0.670,P<0.001;OR=1.261,P=0.001）. Conclusion The incidence of grazing behavior in MBS patients is at a high level with distinct characteristics of classification. Healthcare professionals may design personalized intervention strategies according to the influencing factors of different latent classes of grazing behavior.

Marginal ulcer is a common complication after Roux-en-Y gastric bypass and its improper management may cause serious consequences, including perforation, hemorrhage and stenosis.This report described one female case of anastomotic marginal ulcer after Roux-en-Y gastric bypass. She initially underwent laparoscopic Roux-en-Y gastric bypass in April 2011 for metabolic syndrome.In September 2017, there was an onset of recurrent abdominal pain with altered stool consistency. After thorough examinations, marginal ulcer was diagnosed due probably to an enlargement of gastric pouch. Consequently,in October 2019,laparoscopic sleeve gastrectomy was performed along with partial small bowel resection. Despite regular postoperative dosing of antacids, recurrent abdominal pain, nausea and vomiting persisted. Follow-up gastroscopy revealed non-healing of anastomotic marginal ulcer. In June 2022, after completing thorough preoperative preparation, laparoscopic partial gastric-gastrointestinal anastomosis, nutritional branch jejunostomy and gastric bypass revision were performed. Postoperative symptoms improved markedly. Follow-up gastroscopy at Month 8 showed no sign of ulceration. This case illustrated the challenge of managing marginal ulcers since two revision operations over nearly 5 years were required for curing. Focusing upon the relevant literature on marginal ulcers after Roux-en-Y gastric bypass, this review summarized risk factors, treatments and prevention strategies to provide references for bariatric and metabolic surgeons.

Pancreaticoduodenectomy has been a golden standard for treating benign and malignant lesions of duodenum, distal bile duct and pancreatic head. Postoperative pancreatic fistula may significantly affect the survival and prognosis of patients. Pancreaticojejunostomy is one of the risk factors of postoperative pancreatic fistula. Researchers have modified anastomotic modes and auxiliary materials for minimizing the occurrence of postoperative pancreatic fistula. It may guide clinical decision-making for individualization to provide theoretical rationales for further lowering the incidence of postoperative pancreatic fistula.

Objective To explore the effects of different types of metabolic and bariatric surgery on body weight （BW）, body mass index（BMI）, ovarian morphology, follicle number, menstrual cycle, androgens and anti-mullerian hormone （AMH） in obese patients with polycystic ovary syndrome （PCOS）. Methods From February 2021 to June 2023,70 obese patients with PCOS and 60 obese patients without PCOS admitted were assigned into two groups. For obese patients with PCOS, sleeve gastrectomy （SG, n=35） and Roux-en-Y gastric bypass （RYGB,n=35） were performed. And for obese patients without PCOS, SG（n=30） and RYGB（n=30） were performed. The changes of BW, BMI, ovarian morphology, follicle number, menstrual cycle and androgen/AMH level of two groups were recorded. Results BW and BMI at post-operation were significantly lower than those at pre-operation. Ovarian volume and follicle number declined markedly, menstrual cycle became obviously shortened and AMH/androgen level dropped significantly as compared with those at pre-operation. SG/RYGB demonstrated marked weight loss in both PCOS and non-PCOS obese patients and no significant difference existed in weight loss effect.And RYGB was superior to SG in long-term weight loss, long-term regulation of follicle volume/quantity, long-term improvement of androgen level, short-term adjustment of menstrual cycle and lowering the level of AMH. Conclusion SG/RYGB may significantly relieve PCOS in obese patients.

Objective To explore the changes of body composition in an early stage after bariatric surgery to formulate the nutrition and treatment plan. Methods From March 2019 to April 2022, retrospective analysis was performed for 106 patients undergoing laparoscopic sleeve gastrectomy （LSG）. Bioelectrical resistance analysis （BIA） was utilized for detecting body composition, obesity, muscle, water and nutritional parameters pre-operation and during follow-ups. Results LSG was all successfully performed. There were 40 （37.7%） males and 66 （62.3%） females with an average age of （28.4±7.2） year. 85 patients （80.2%）, 72（67.9%）, 65（61.3%） and 60（56.6%） were followed up at Month 1/3/6/12. Body weight, total body water （TBW）, protein, minerals, body fat mass （BFM）, soft lean mass and fat-free mass declined post-operation. Body weight and BFM dropped from （108.6±20.5） and （49.8±12.8） to （72.4±14.7） and （20.1±5.7） kg at Month 12 post-operation. Body mass index （BMI）, percent body fat （PBF）, waist-hip ratio, visceral fat area （VFA）, obesity degree and BFM of limbs/trunk showed a progressive decline. At Month 12 post-operation, BMI decreased from （38.6±5.9） to （26.2±4.6） kg/m², PBF dropped from （45.4±5.2）% to （26.9±6.2）% and VFA declined from （173±46） to （78±32） cm². Skeletal muscle mass, arm circumference, arm muscle circumference, muscle mass of upper limbs and trunk decreased in different degrees at Month 6 post-operation. Muscle mass of lower limbs decreased and stabilized at Month 1 post-operation. Intracellular water and extracellular water （ECW） declined while ECW/TBW rose at Month 3 post-operation. InBody score increased at Month 3 and 6 post-operation than that of the previous follow-up time point and body cell mass showed a lowering trend at Month 3 post-operation. Conclusion Body composition changes after bariatric surgery. Thus it may provide scientific rationales for weight control, muscle gain/loss and nutrition balance.

Objective To explore the clinical efficacy of transanal anastomotic drainage for colorectal anastomotic leakage and examine its impact on anal function and quality-of-life. Methods From January 1, 2007 to December 31, 2023, the relevant clinical data were retrospectively reviewed for 1 016 patients undergoing colorectal anastomosis. Postoperative anastomotic leakage occurred in 218 patients and colostomy was repeated in 15 patients due to severe abdominal infection and diffuse peritonitis. And 115 patients of anastomotic leakage improved after conservative measures and 10 cases could not be followed up due to missing data. Finally the relevant clinical data were retrospectively reviewed for 78 patients of anastomotic leakage. They were assigned into two groups of transanal drainage （study, n=18） and simple transabdominal drainage （control, n=60）. They were examined by assessment scales of low anterior resection syndrome （LARS） and Wexner fecal incontinence and European Organization for Research and Treatment of Cancer （EORTC）. And EORTC Quality-of-Life Scale （EORTC QLQ-C30） was employed for assessing postoperative quality-of-life and anal function. Results After colorectal operation, 78 patients of anastomotic leakage were cured and discharged from hospital. No obvious diffuse peritonitis or abdominal infection occurred. Both groups were followed up for 3 months post-discharge. There was no recurrence of tumor, anastomotic stenosis or scar hyperplasia. Anal function： As compared with control group, the scores of LARS [（20.28±9.95） vs. （25.55±11.71） points] and Wexner [（10.56±2.36） vs. （13.00±2.52） points] were lower in study group pre-catheterization and the differences were statistically significant （all P<0.05）. However, there was no significant inter-group difference post-catheterization （all P>0.05）. EORTC QLQ-C30 quality-of-life： Prior to catheterization, study group demonstrated worse performance in the domains of role function, social function and respiratory symptoms than those in control group. And the differences were statistically significant （all P<0.05）. However, no significant inter-group difference existed in EORTC QLQ-C30 score post-catheterization （all P>0.05）. Conclusion Catheter irrigation and drainage through anal anastomotic leakage may be an important treatment for patients of anastomotic leakage after colorectal surgery. As anal function is restored after surgery, quality-of-life improves, rate of anastomotic stenosis drops and the chance of a second stomy is minimized. This safe treatment is worthy of wider clinical applications

Objective To explore the clinicopathological features, treatments and outcomes of follicular dendritic cell sarcoma （FDCS） in abdomen. Methods One rare case of pancreatic FDCS was reported in the Second Affiliated Hospital of Shaanxi University of Chinese Medicineand the relevant case reports in both domestic and foreign literatures were reviewed. Results A 66-year-old female patient with pancreatic FDCS was hospitalized for physical examination detecting a space-occupying lesion at tail of pancreatic body. Computed tomography （CT） indicated that tumor with a size of around 9 cm had distinct boundaries with a compression of splenic vein. Tumor marker CA125 was elevated. During pancreatic-caudal splenectomy, tumors presented spindles with distinct nucleolus and obvious mitosis. With the findings of CD21, CD35, fascin （+）, EBER in situ hybridization （-） and Ki-67 around 20%, pathological diagnosis was pancreatic FDCS. No other adjuvant treatment was offered. No recurrence or metastasis occurred during a follow-up period of 6 months. And 49 cases of abdominal FDCS were retrieved from a literature review. For a total of 50 cases, the average age was 50（19-77） year and most of them had a non-specific medical history. Liver and retroperitoneal cavity are dominant and spleen, large intestine, pancreas, small intestine, ileocecal part and appendix are also common sites. No significant inter-gender difference existed. Generally patients may have no obvious symptoms or varying severity of abdominal symptoms. Some dermal and pulmonary symptoms are extra-abdominal. Preoperative laboratory tests revealed no obvious abnormalities and tumor marker CA125 was elevated in 10% of patients. Ultrasonography and CT are two major auxiliary examinations. Colonic polyps is often detected under endoscope. And 22% of patients had metastases at an initial visit. Almost all macroscopic slides showed single solid tumors with distinct boundaries and maximal diameter of tumor was （1-30） cm. A definite diagnosis is often dependent upon a combination of several specific markers such as CD21, CD35, Fascin, CD23 and fascin plus histology. Most EBER in situ hybridizations was positive. And 96% of them were operated. Most of them survived tumor-free post-operation and few had recurrence and metastasis. Adjuvant chemotherapy or radiotherapy was rare. And efficacy should be further confirmed. Conclusion As a kind of rare moderate malignant tumor, abdominal FDCS carries a high risk of local recurrence and metastasis after excision and lacks a specificity of clinical pathogenesis. Its pathogenesis may be correlated with Epstein-Barr virus infection and immune system diseases. Whether or not postoperative chemoradiotherapy improves its prognosis remains uncertain. However, if high risk factors are present, long-term follow-ups, regular reviews and aggressive interventions are recommended.

Objective To evaluate the immediate efficacy of transumbilical laparoendoscopic single-site surgery （TU-LESS） for Hirschsprung's disease （HSCR） with oblique mucosectomy and anastomosis with a short split muscular cuff.Methods From January 2014 to December 2019, the relevant clinical data were retrospectively reviewed for 163 HSCR children. According to specific surgical approaches, they were divided into two groups of TU-LESS with oblique mucosectomy and anastomosis with a short split muscular cuff （TU-LESS group） and conventional laparoscopy preserving traditional muscle cuff （CLS group）. Operative duration, volume of intraoperative hemorrhage, postoperative hospitalization stay, recovery time of digestive function, perioperative complications and postoperative SCAR were compared between two groups.Results All operations were successfully completed. Three patients in CLS group were converted into open surgery while umbilical incision of 2 cases was expanded in TU-LESS group. The incidence rates of postoperative enterocolitis, anastomotic stenosis and the scores of SCAR （Scar Cosmesis Assessment and Rating） scale were lower in TU-LESS group than those in CLS group （P<0.05）. No inter-group differences existed in other observation parameters （P>0.05）.Conclusion TU-LESS with oblique mucosectomy and anastomosis with a short split muscular cuff is both safe and efficacious for HSCR. And cosmetic effect is better than that of conventional laparoscopy and there is a lower incidence of anastomotic stenosis and enterocolitis.

Objective To explore the clinical application value of right hepatic parenchymal transection-first approach during laparoscopic resection of benign occupation lesions in superior segment of right hepatic posterior. Methods From January 2022 to January 2024, the relevant clinical data were retrospectively reviewed for 21 laparoscopic resections for benign occupation lesions in superior segment of right hepatic posterior by right hepatic parenchymal transection-first approach. Operative duration, intraoperative volume of blood loss, postoperative hemorrhage, bile leakage and postoperative hospital stay were recorded. Results There was no instance of intraoperative blood transfusion, conversion into laparotomy or severe complications. The pathological diagnoses were hepatic hemangioma （n=11）, focal nodular hyperplasia （n=6） and hepatic adenoma （n=4）. Average operative duration of laparoscopic group was （310±10） min, average volume of blood loss （300±87） mL and postoperative hospitalization stay （7±3） day. Conclusion Right hepatic parenchymal transection-first approach for laparoscopic resection of benign occupation lesions in superior segment of right hepatic posterior is both safe and efficacious. It may shorten operative duration, boost operative safety and lower operative difficulty. A wider popularization is worthwhile.

对成都市郫都区人民医院2023年3月31日收治的1例成人肝淋巴管瘤临床资料及治疗方案进行总结,并回顾性分析国内外肝淋巴管瘤相关文献。该病人因“右上腹疼痛1年”入院,上腹部增强CT：肝右前叶可见多个囊状影,中间见钙化灶,最大层面大小约5.4 cm×3.6 cm,部分囊内见线状稍高密度影,增强后囊壁强化,考虑囊性占位,寄生虫感染待排,或其他。结合病人无疫区接触史,术前考虑肝囊腺瘤。于2023年4月6日行肝S5、S8段不规则性切除术。术后病检及免疫组化提示肝淋巴管瘤。肝淋巴管瘤及肝囊腺瘤两者在CT影像学诊断上极易误诊。两者均为肝囊性占位,且多有分隔,增强后囊壁及分隔均有强化。鉴别要点主要在肝囊腺瘤囊内多伴有壁结节或乳头状突起,少有钙化,而肝淋巴管瘤囊内多伴有钙化,无壁结节。

报道1例先天性巨大膈疝病人,完善术前准备后,经全程腹腔镜入路无张力修补完成手术。即全腹腔镜下将胸腔内疝入脏器还纳腹腔后,用倒刺线缝合缺损膈肌,放置10 cm×15 cm生物疝补片,用生物胶粘牢固定补片。术后1年随访中,病人既往呼吸系统及消化系统不适体征均已消失。复查影像检查未见复发及其他并发症。此类病人及手术方式罕见,报道为巨大膈疝治疗及手术方式选择提供参考。

Objective To explore the risk factors of acute appendicitis （AA） with perforation. Methods From January to June 2023, a total of 212 hospitalized AA patients were selected as study subjects. According to the observation of appendix and pathological results, they were assigned into two groups of non-perforated （n=169） and perforated （n=43）. Demographic profiles （e.g. gender, age & duration of onset）, blood test parameters （e.g. blood routine, total bilirubin & D-dimer） and imaging findings （whether or not fecalith within appendix and ascites in abdominal cavity） were compared between two groups. The influencing factors of perforated AA were examined by multivariate Logistic regression analysis and receiver operating characteristic （ROC） curve. Results There were 43 cases of perforated AA with a perforation rate of 20.3%. Longer symptomatic duration, fever （axillary temperature ≥ 38 ℃）, appendiceal fecalith on imaging, ascites on imaging and elevated level of C-reactive protein （CRP） were independent risk factors for perforated AA were examined by single factor and multiple factor Logistic regression （P< 0.05）. The area under the ROC curve of longer symptomatic duration, ascites and CRP level were 0.827, 0.853 and 0.810 （P< 0.05）. When all parameters were combined for prediction, AUC was 0.962 with a sensitivity of 0.884 and a specificity of 0.893. Conclusion Longer symptomatic duration, fever （axillary temperature ≥ 38 ℃）, appendiceal fecalith on imaging, ascites on imaging and elevated CRP level are independent risk factors for perforated AA. There is a higher value when all parameters are combined for assessments.

Objective To evaluate the feasibility and effectiveness of methylene blue staining via nasopancreatic tube during pancreatic enucleation. Methods A retrospective analysis was conducted on the medical records and follow-up data of 18 patients who underwent pancreatic enucleation with intraoperative methylene blue staining via nasopancreatic tube at the Pancreatic Surgery Department of Renmin Hospital of Wuhan University from May 2020 to September 2024. Among these patients,15 had tumors located in the pancreatic head and neck,and 3 in the body and tail.The maximum tumor diameter was 2.3±0.7 cm, and the shortest distance between the tumor margin and the main pancreatic duct was 2.2±0.6 mm. All patients had nasopancreatic tubes placed preoperatively under endoscopic guidance.During surgery,methylene blue solution was injected through the nasopancreatic tube after tumor enucleation to observe the staining of the pancreatic wound surface.Appropriate repair methods were selected based on the location of pancreatic juice leakage,and postoperative short-and long-term complications were recorded and analyzed,with a particular focus on the occurrence of postoperative pancreatic fistula（POPF）. Results Intraoperative injection of methylene blue solution revealed staining of the wound surface in 6 cases. According to the International Study Group on Pancreatic Fistula （ISGPF） criteria for POPF, a total of 10 patients experienced pancreatic fistula and biochemical leak postoperatively. Among these, there were 7 cases of biochemical leak and 3 cases of grade B POPF, without occurrences of grade C POPF. Conclusion The application of methylene blue staining via nasopancreatic tube during pancreatic enucleation is safe and feasible.It facilitates the timely and accurate detection of pancreatic juice leakage that may not be visible to the naked eye,enabling immediate repair and reducing the risk of postoperative complications, particularly pancreatic fistula.