Pancreaticoduodenectomy Surgery Research Articles

Postoperative fluid therapy in enhanced recovery after surgery for pancreaticoduodenectomy.

Optimal intravenous fluid management during the perioperative period for patients undergoing pancreaticoduodenectomy (PD) within the framework of enhanced recovery after surgery (ERAS) is unclear. Studies have indicated that excessive total body salt and water can contribute to the development of oedema, leading to increased morbidity and extended hospital stays. This study aimed to assess the effects of an intravenous therapy regimen during postoperative day (POD) 0 to 2 in PD patients within ERAS. A retrospective interventional cohort study was conducted, and it involved all PD patients before and after implementation of ERAS (2009-2017). In the ERAS group, a targeted maintenance fluid regimen of 20 mL/kg/day with a sodium requirement of 0.5 mmoL/kg/day was administered. Outcome measures included the mmol of sodium and chloride administered, length of stay, and morbidity (postoperative pancreatic fistula, POPF; acute kidney injury, AKI; ileus). The study included 169 patients, with a mean age of 64 ± 11.3 years. Following implementation of the intravenous fluid therapy protocol, there was a significant reduction in chloride and sodium loading. However, in the multivariable analysis, chloride administered (mmoL/kg) did not independently influence the length of stay; or rates of POPF, ileus, or AKI (p > 0.05). The findings suggested that a postoperative intravenous fluid therapy regimen did not significantly impact morbidity. Notably, there was a trend towards reduced length of stay within an increasingly comorbid patient cohort. This targeted fluid regimen appears to be safe for PD patients within the ERAS program. Further prospective research is needed to explore this area.

Can the surgeon prolong the remaining life of the patient in pancreaticoduodenectomy surgery? or is the surgeon helpless?

Can the surgeon prolong the remaining life of the patient in pancreaticoduodenectomy surgery? or is the surgeon helpless?

Can the surgeon prolong the remaining life of the patient in pancreaticoduodenectomy surgery? or Is the surgeon helpless?

We aimed to evaluate the effects of R0 and R1 resections after pancreatic surgery. Data of 130 patients were evaluated. Re-resection was performed in patients who were found to have R1 resection after frozen section (FS). Overall survival (OS), disease free survival (DFS) among patients with R1 resection in paraffin section (PS) (n:28, Group1) and patients who underwent re-resection after FS and achieved the R0 resection goal in PS (n:16, Group 2) (DFS), local recurrence and systemic metastasis results were compared. Tumor diameter, differentiation, age and complications were found to negatively affect OS. It was observed that DFS increased (p:0.02) and local recurrence rates decreased (p:0.037) in group 2 compared but there was no difference between the two groups in terms of OS (p:0.420) and systemic metastasis (p:0.467). R0 resection obtained by surgical margin resection of the neck in pancreatic head adenocarcinomas decreases local recurrence and increases the duration of DFS. However, it has no effect on preventing OS and systemic metastasis.

The Effect of Increase in Clinical Experience on Morbidity and Mortality After Pancreaticoduodenectomy Surgery

<b> Introduction:</b> Pancreaticoduodenectomy surgery is widely accepted and applied worldwide for periampullary tumors. Despite the decline in mortality rates from 40% to 3% with the advances in surgical technique, morbidity is still high (40–50%). </br></br> <b>Aim:</b> We aimed to investigate the effect of increased clinical experience on the length of hospital stay, morbidity, mortality, and survival after pancreaticoduodenectomy. </br></br> <b> Materials and methods:</b> The files of patients who underwent pancreaticoduodenectomy in our hospital between January 2007 and January 2018 were retrospectively reviewed and divided into four groups by years. Demographics, body mass index (BMI, kg/m2), medical history, preoperative biliary drainage application, surgical technique, histopathological features, postoperative morbidity, mortality, and survival were investigated. </br></br> <b> Results: </b> There was no difference between the groups in terms of age, gender, comorbid disease, history of biliary drainage, surgical technique, and operation time (P > 0.05). The rate of postoperative complications has decreased over the years (P = 0.01). According to the Clavien-Dindo scale, the complication severity decreased significantly over the years (P = 0.05). The overall survival of the patients increased by years (P = 0.03); the Early postoperative mortality rate decreased in the first month (<30 days) (P = 0.04). </br></br> <b> Conclusion:</b> With increased clinical experience, morbidity and mortality decrease, overall survival is prolonged after pancreaticoduodenectomy procedure.

Opioid Sparing Anesthesia and Enhanced Recovery After Surgery Protocol for Pancreaticoduodenectomy.

BackgroundOpioid sparing anesthesia and enhanced recovery after surgery protocols are not innovative ideas. However, the utilization of pancreaticoduodenectomy is limited. With the rise in awareness of the opioid epidemic in the United States, we have created a multimodal approach to anesthesia and postoperative care to limit adverse effects of opioids and curb the use of opioids postoperatively.MethodsWe conducted a retrospective cohort study performed by chart review of an opioid-sparing anesthetic and enhanced recovery after surgery (ERAS) protocol initiated jointly by the anesthesiology departments and transplant surgery for pancreaticoduodenectomy from January 2017 to October 2019.ResultsDemographic data was found to be comparable between the control and protocol groups. Hospital length of stay, ICU length of stay, and opioid requirements significantly decreased in the protocol group. Hospital length of stay decreased from 8.92 to 5.72 days, ICU days decreased from 1.52 to 0.42 days, and narcotics for the first five hospital days were significantly decreased from 130.13 to 71.2 morphine milligram equivalents.ConclusionProper postoperative pain management can improve patient satisfaction and decrease complication rates. Pancreaticoduodenectomy is a complicated procedure with relatively limited data regarding enhanced recovery after surgery protocols. Likewise, there is limited data regarding opioid-sparing anesthesia techniques. Our protocol produced promising hospital length of stay and reduced opioid administration during the first five hospital days without increasing 30-day readmission rates.

Implementation and controversies of enhanced recovery after surgery in pancreaticoduodenectomy

The concept of enhanced recovery after surgery(ERAS) has been widely accepted and applied in clinical practice.However,as one of the most complex surgical procedures in abdominal surgery,pancreaticoduodenectomy is characterized by long operation time,high incidence rate of postoperative complications and delayed recovery,there still remain some controversies about application of ERAS approaches in perioperative managements of pancreaticoduodenectomy.Although more and more studies has revealed the safety and efficacy of ERAS approaches in pancreaticoduodenectomy,the implementation of ERAS approaches should be still individualized in clinical practice to ensure safety of the patients.

Hepatic artery resection without reconstruction in pancreatoduodenectomy.

It has been reported that there are left and right hepatic arterial arcades via the blood vessels around the hilar bile duct; therefore, when the hilar bile duct is preserved, hepatic artery reconstruction may not be necessary. We compared the short-term and long-term outcomes in patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy (PD) with right hepatic artery resection without right hepatic artery reconstruction (RHAR group) with those patients who underwent conventional PD. All data were retrospectively collected from patient records. A 1:4-propensity score-matched case-control study was conducted in patients with distal cholangiocarcinoma who received treatment at Tokyo Women's Medical University from February 1985 to April 2015. There was no statistical difference in the overall morbidity rate between the two groups. No patient in the RHAR group (10 patients) had liver failure, liver abscess, or cholangitis in the postoperative period; one patient died postoperatively because of a bleeding pseudoaneurysm in the gastroduodenal artery. The PD group (40 patients) had a significantly better median time regarding the recurrence (34 vs. 11 months, p=0.027) and 5-year disease-free survival (35% vs. 10%, p=0.027) rates than the RHAR group, which may be attributed to the presence of a more severe disease in patients in the RHAR group. We concluded that pancreaticoduodenectomy with right hepatic artery resection without reconstruction has a comparable overall morbidity rate with that of a conventional pancreaticoduodenectomy surgery and may be performed as an alternative procedure when tumor invasion of the right hepatic artery is suspected.

加速康复外科在胰十二指肠切除术中的应用

加速康复外科(enhanced recovery after surgery, ERAS)已在全球范围内实施，有强有力的证据表明，遵守ERAS方案可以减少围术期应激反应及医疗并发症、费用，缩短住院时间，促进病人康复。而胰十二指肠切除术(PD)作为普通外科较为复杂的手术之一，存在术后有较高的并发症发生率及死亡率等问题，患者术后生存质量及远期疗效也不理想，ERAS理念及路径在胰腺外科领域应用不多，相关研究的数量与质量均很有限，导致临床对在胰十二指肠切除术中开展加速康复外科的认可度、接受度特别是对于是否行术前营养支持、术后鼻胃管和腹腔引流管拔除时机，术后生长抑素使用与否等几个关键问题存在较大争议，使得一小部分患者在胰十二指肠切除术后未能从ERAS项目中获益。本文针对PD特点，从术前干预、术中和术后管理三个层面详细阐述ERAS在PD的应用进展。 Enhanced recovery after surgery (ERAS) pathways are now implemented worldwide with strong evidence that adhesion to such protocol reduces medical complications, costs, hospital stay and promotes patient. Pancreaticoduodenectomy (PD), as one of the more complicated general surgery procedures, has problems such as high postoperative complications and mortality, and the quality of life and long-term efficacy of patients are not ideal. , ERAS concept and path are not widely applied in the field of pancreatic surgery, and the quantity and quality of related research are very limited, which leads to clinical recognition and acceptance of accelerated rehabilitation surgery in pancreaticoduodenectomy, especially whether it is feasible or not. Several key issues such as preoperative nutritional support, postoperative nasogastric tube and abdominal drainage tube removal timing, and postoperative somatostatin use are controversial, making a small number of patients fail after pancreaticoduodenectomy. Can benefit from the ERAS project. According to the characteristics of PD, this article elaborates on the application progress of ERAS in PD from three levels of preoperative intervention, intraoperative and postoperative management.

Mitigation of robotic pancreaticoduodenectomy learning curve through a comprehensive training program

Background: The utilization of robotic surgery for pancreaticoduodenectomy continues to increase. There is an apparent associated lag in the training for this complex operation resulting in a learning curve with the adoption of this technique. We hypothesize that the reported learning curve can be mitigated through a comprehensive graduated training protocol. Methods: Prior to robotic pancreaticoduodenectomy program implementation, all surgeons (n=3) and operating room staff at The Ohio State University underwent dedicated training. All patients who underwent an open (n=156) or robotic (n=41) pancreaticoduodenectomy following program implementation between 2015-2018 were identified. Operative and post-operative outcomes over time were analyzed. Robotic and open patients were matched 1:1 based on all measurable pre-operative patient- and tumor-specific risk factors. Results: The unplanned robotic-to-open conversion rate was 19.5% (n=8). Of the remaining 33 robotic whipple operations, operative time plateaued at 11 cases (figure); however, mean operative time did not change over time (P=0.08). Similarly, no difference over time was seen in the rate of grade B/C postoperative pancreatic fistula (POPF) (n=9.1%) or need for blood transfusion (n=4, 12,1%) (P=1.00). After matching, no difference was seen between robotic and open operations in the incidence of grade b/c POPF, delayed gastric emptying, length of stay, readmission, major complications, and death (all P>0.05). Conclusion: Through a graduated comprehensive training protocol, there was no apparent learning curve associated with the implementation of robotic pancreaticoduodenectomy as described in previous studies. Furthermore, robotic cases had similar postoperative outcomes compared to matched open cases.

Preoperative cholangitis is an independent risk factor for mortality in patients after pancreatoduodenectomy for pancreatic cancer

ObjectivesPreoperative biliary stenting is required for patients with obstructive jaundice from pancreatic adenocarcinoma who are receiving neoadjuvant chemotherapy. While in most patients this approach results in durable biliary drainage, some patients develop cholangitis during neoadjuvant treatment. Further, several studies have shown that preoperative cholangitis in patients with hepatobiliary malignancies can result in substantially unfavorable outcomes. The aim of this study was to evaluate the impact of preoperative cholangitis in patients who underwent pancreaticoduodenectomy after completing neoadjuvant chemotherapy. MethodsParticipants: all adult patients (n = 449) diagnosed with pancreatic adenocarcinoma from January 1st, 2013 to March 31st, 2018 who pursued treatment at the Massachusetts General Hospital were screened. Of these 449 patients, 97 met final inclusion criteria of receiving neoadjuvant chemotherapy with intent to pursue curative surgery. Data were collected via retrospective chart review including baseline characteristics, survival, episodes of preoperative cholangitis, and surgical complications. ResultsIn patients completing successful pancreaticoduodenectomy surgery, preoperative cholangitis is associated with increased mortality (HR 2.67, 95% CI:1.16–6.13). This finding is independent of postoperative outcomes or tumor recurrence rate. The presence of cholangitis did not impact completion of neoadjuvant chemotherapy (92% vs 85%, p = 0.5) or ability to proceed to surgery (76% vs 75%, p = 1.0). Preoperative cholangitis was not associated with postoperative morbidity (42.1% vs 45.1%, p = 1.0). ConclusionsOne episode of cholangitis during neoadjuvant chemotherapy is associated with increased mortality following successful pancreaticoduodenectomy, independent of immediate postoperative outcomes or tumor recurrence. Preoperative cholangitis does not affect ability to pursue neoadjuvant chemotherapy or complete successful surgery. Patients who develop cholangitis during the neoadjuvant chemotherapy treatment phase may reflect a distinct phenotype of patients with PDAC with a complex and more challenging clinical course.

Advancing the Time to the Initiation of Adjuvant Chemotherapy and Improving Postoperative Outcome: Enhanced Recovery after Surgery in Pancreaticoduodenectomy

Early initiation of chemotherapy could improve overall survival after pancreaticoduodenectomy (PD). The concept of enhanced recovery after surgery (ERAS), which aims to reduce the stress response to surgery and accelerate recovery, is relatively limited in PD. The aim of the study was to retrospectively analyze the relationships of ERAS with the time of initiation of postoperative chemotherapy and recovery in PD patients. Between January 1, 2008 and December 31, 2017, all patients who underwent open PD for malignant tumor at our unit were studied retrospectively. Patients were divided into ERAS and conventional groups. The time to initiation of adjuvant chemotherapy and postoperative outcomes were analyzed. There were 344 consecutive patients in this study, with 203 patients in the ERAS group. There were no significant differences between the ERAS and conventional groups in morbidity, mortality, and readmission. The median time of initiation of adjuvant chemotherapy in the ERAS group (54.1 days) was significantly shorter than that of initiation of adjuvant chemotherapy in the conventional group (67.8 days). The ERAS group had a shorter postoperative length of stay than the conventional group (14.9 vs 19.3 days). The ERAS program is safe and feasible in PD. These protocols improve postoperative recovery and advance the time of initiation of adjuvant chemotherapy.

A rare case of pancreatic neuroendocrine tumor

Pancreatic neuroendocrine tumors (PNETs) are a group of endocrine neoplasms that exhibit neuroendocrine phenotypes. These include the production of neuropeptides, large dense-core secretory vesicles, and a lack of neural structures. They arise in the pancreas and are among the most common neuroendocrine tumors. A case of 38 years old female presented with a painless progressive swelling in the right upper abdomen since one month which is insidious in onset, gradually increasing in size with a history of significant weight loss and patient is not a known diabetic. On Examination, a swelling of size 5x7cm noted involving epigastric and right hypochondrium, which is not moving with respiration and dull on percussion. Plane of swelling is Intra-abdominal& retroperitoneal. Computed tomography abdomen (CECT) showed well defined rounded iso dense lesion showing heterogeneous enhancement in arterial and venous phase. Magnetic resonance cholangiopancreatography (MRCP) showed well defined lobulated heterogeneous solid lesion with central areas of necrosis seen in the pancreaticoduodenal groove (PDG) involving main pancreatic duct (MPD) and loss of fat planes with surrounding structures most likely malignant etiology. The patient underwent pancreaticoduodenectomy surgery (Whipple procedure) and had an uneventful recovery. Post-operative biopsy report confirmed pancreatic neuroendocrine tumor grade II (well-differentiated type), stage II a – pT3 N0 Mx.

Enhanced recovery after surgery for pancreaticoduodenectomy: Possible, but justified?

Background: Enhanced recovery after surgery (ERAS) is proven to reduce hospitalization and perioperative complications. With the postoperative journey following pancreaticoduodenectomy (PD) being complex, the implementation of ERAS for these patients has been met with hesitancy. We present our experience in implementing an enhanced recovery protocol after PD. Methods: A systematic ERAS protocol was developed and implemented for all patients undergoing PD. A prospectively maintained database allowed comparison of ERAS against pre-ERAS patients. Results: 57 patients were included with 36 ERAS patients and 21 pre-ERAS patients. No differences were found in age (66.3 vs 61.2, p = 0.24), BMI (24.4 vs 24.9 p = 0.59), pathological diagnosis (66% vs 71% pancreatic adenocarcinoma), vascular reconstruction (13% vs 14%, p = 0.857) or Charlson score (5.3 vs 4.7, p = 0.820). Pancreatic texture and duct diameter were similar. One mortality occurred in the ERAS group. The incidence of postoperative complications was identical. Grade B or C pancreatic fistulation occurred in 19% of patients in each group (p = 0.97) whilst delayed gastric emptying occurred in 22.2% vs 19.1% (p = 0.77). Unplanned readmissions was comparable (34.3% vs 38.6% p = 0.81) as was length of stay (18.8 days vs 17.7 days, p = 0.59). Conclusion: The implementation of an ERAS protocol failed to reduce the incidence of complications, unplanned readmissions or decrease the length of stay in patients undergoing PD.

Enhanced recovery after surgery for pancreaticoduodenectomy: possible, but justified?

Background: Enhanced recovery after surgery (ERAS) is proven to reduce hospitalization and perioperative complications. With the postoperative journey following pancreaticoduodenectomy (PD) being complex, the implementation of ERAS for these patients has been met with hesitancy. We present our experience in implementing an enhanced recovery protocol after PD. Methods: A systematic ERAS protocol was developed and implemented for all patients undergoing PD. A prospectively maintained database allowed comparison of ERAS against pre-ERAS patients. Results: 57 patients were included with 36 ERAS patients and 21 pre-ERAS patients. No differences were found in age (66.3 vs 61.2, p = 0.24), BMI (24.4 vs 24.9 p = 0.59), pathological diagnosis (66% vs 71% pancreatic adenocarcinoma), vascular reconstruction (13% vs 14%, p = 0.857) or Charlson score (5.3 vs 4.7, p = 0.820). Pancreatic texture and duct diameter were similar. One mortality occurred in the ERAS group.The incidence of postoperative complications was identical. Grade B or C pancreatic fistulation occurred in 19% of patients in each group (p = 0.97) whilst delayed gastric emptying occurred in 22.2% vs 19.1% (p = 0.77). Unplanned readmissions was comparable (34.3% vs 38.6% p = 0.81) as was length of stay (18.8 days vs 17.7 days, p = 0.59). Conclusion: The implementation of an ERAS protocol failed to reduce the incidence of complications, unplanned readmissions or decrease the length of stay in patients undergoing PD.

Targeted perioperative fluid therapy in enhanced recovery after surgery in pancreaticoduodenectomy

Targeted perioperative fluid therapy in enhanced recovery after surgery in pancreaticoduodenectomy

Novel use of REDCap to develop an advanced platform to display predictive analytics and track compliance with Enhanced Recovery After Surgery for pancreaticoduodenectomy

BackgroundPrediction models are increasingly being used with clinical practice guidelines to inform decision making. Enhanced Recovery After Surgery (ERAS®) protocols are standardized care pathways that incorporate evidence-based practices to improve patient outcomes. Predictive analytics incorporated within a data management system, such as Research Electronic Data Capture (REDCap), may help clinicians estimate risk probabilities and track compliance with standardized care practices. MethodsPredictive models were developed from retrospective data on 400 patients who underwent pancreaticoduodenectomy from 2008 through 2014. The REDCap was programmed to display predictive analytics and create a data tracking system that met ERAS guidelines. Based on predictive scores for serious complication, 30-day readmission, and 30-day mortality, we developed targeted interventions to decrease readmissions and postoperative laboratory tests. ResultsPredictive models demonstrated a receiver-operating characteristic area (ROC) ranges of 641–856. After implementing the REDCap platform, the readmission rate for high-risk patients decreased 15.8% during the initial three months following ERAS implementation. Based on predictive outputs, patients with a low-risk score received a limited set of postoperative laboratory tests. Targeted interventions to decrease hospital readmission for high-risk patients included home care orders and post-discharge instructions. ConclusionsThe REDCap platform offers hospitals a practical option to display predictive analytics and create a data tracking program that meets ERAS guidelines. Prediction models programmed into REDCap offer clinicians a support tool to assess the probability of patient outcomes. Risk calculations based on predictive scores enabled clinicians to titrate postoperative laboratory tests and develop post-discharge home care orders.

Predictors of Intraoperative Pressure Injury in Patients Undergoing Major Hepatobiliary Surgery.

The purpose of this study was to identify risk factors associated with pressure injury (PI) development in patients undergoing major hepatobiliary surgery requiring general anesthesia. Retrospective medical review and analysis. Medical records from 803 patients undergoing hepatobiliary surgery from October 2015 to October 2016 were reviewed. The study setting was a 3400-bed military academic medical center in the northeast region of China. Demographic variables, comorbid conditions, preoperative Braden Scale for Pressure Sore Risk scores, preoperative serum hemoglobin and albumin levels, type of surgery, positioning, surgical time, hypotensive episodes, blood loss, body temperature, and other potential risk factors for PI development were collected. Pressure injury occurrences during a 48-hour period after surgery were recorded along with stage. Data were analyzed using univariate analyses and multivariate logistic regression analysis to build a predictive model for factors associated with PI occurrences. The prevalence of PIs in major hepatobiliary surgery patients was 19.8%, 4.9%, and 4.1% in the immediate postoperative period, on the first day and the second day after surgery, respectively. Pancreaticoduodenectomy surgery (odds ratio [OR]: 3.957, 95% confidence interval [CI]: 2.145-7.302, P < .001), open surgery (OR: 2.917, 95% CI: 1.558-5.463, P = .001), surgical time (cutoff point at 197 minutes for increased risk of PI, OR: 1.004, 95% CI: 1.002-1.006, P = .001), and intraoperative hypotensive episodes (OR: 1.022, 95% CI: 1.005-1.039, P = .010) were associated with an increased likelihood of PI development. Among patients undergoing major hepatobiliary surgery such as pancreaticoduodenectomy, prolonged surgical time, open surgery, and intraoperative hypotension were found to be associated with an increased likelihood of developing a PI. Maintaining hemodynamic stability and taking more effective measures for skin care during these procedures may reduce the risk of PI in this vulnerable population.

Reducing postoperative complications and improving clinical outcome: Enhanced recovery after surgery in pancreaticoduodenectomy – A retrospective cohort study

BackgroundAn enhanced recovery after surgery (ERAS) programme aims to reduce the stress response to surgery and thereby accelerate recovery. The experience of implementing the ERAS programmes in pancreatoduodenectomy (PD) is relatively limited. The aim of this study was to evaluate the feasibility, safety and clinical outcomes of the ERAS programme after PD at a high-volume Chinese university referral centre. MethodsBetween September 2014 and July 2016, a retrospective analysis of 166 consecutive patients who underwent PD at a tertiary referral care center was carried out. Ninety-eight patients who received conventional perioperative management (the conventional group) were compared with 68 patients who received ERAS programme (the ERAS group). The incidences of postoperative complications, length of stay, expenses, postoperative readmissions, and reoperation rates were compared. ResultsA total of 166 patients who underwent PD were analysed (68 patients in the ERAS group, and 98 patients in the conventional group). There were no significant differences in mortality, reoperation, and readmission rates. The ERAS group had a lower morbidity rate than the conventional group (50% vs. 90.8%; P = 0.00), as well as a shorter length of hospital stay (7.5 vs 12 days; P = 0.00). Delayed gastric emptying was significantly reduced in the ERAS group (0 vs. 11.2%; P = 0.011). Pancreatic fistula (grade B,C) was significantly reduced in the ERAS group (14.7 vs 30.6%; P = 0.018). The median total hospital cost was also significantly reduced in the ERAS group (¥79790.40 vs ¥102982.81; P = 0.000). ConclusionThe ERAS programme is feasible and safe in patients who underwent PD, and it can reduce postoperative complications and improve clinical outcomes.

Superior mesenteric artery margin in pancreaticoduodenectomy for pancreatic adenocarcinoma.

The aim of this study is trying to describe more details of superior mesenteric artery margin in pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, to evaluate biological and prognostic implications of tumor budding in this margin, and to provide more evidence for evaluation of R0 surgery in pancreaticoduodenectomy. 46 patients in 5-years period are included in this study. Immunochemistry and immunofluorescence are used to analyze tumor budding and epithelial–mesenchymal transition. Superior mesenteric artery margin might be described from four aspects including location, gross appearance, microscopic appearance and tumor budding. We find that 1mm rule for R1 surgery is more appropriate to predict prognosis (P = 0.009) than 0mm rule (P = 0.141). Expression of cytokeratin in tumor budding is significantly lower than primary tumor (P = 0.001), and it suggests that tumor budding may participate the procedure of epithelial–mesenchymal transition. High-grade tumor budding and decreasing cytokeratin of tumor budding correlate with distant metastasis and has negative influence on prognosis. So superior mesenteric artery margin might be not only an area that tumor cells may invade, but also a pathway for distant metastasis. It is necessary to evaluate superior mesenteric artery margin in pancreaticoduodenectomy for pancreatic cancer.

Progress of application for enhanced recovery after surgery in pancreaticoduodenectomy

Due to the large surgical trauma and postoperative complications, the perioperative management of pancreaticoduodenectomy has been one of the urgent problems to be solved by the surgeons. With the development of modern medicine, enhanced recovery after surgery (ERAS) comes into being, basing on anti-stress mechanism and multi-disciplinary team, and the perioperative management of pancreaticoduodenectomy has been optimized and improved continuously. The surgeons through a range of measures that had evidence-based medicine basis to mitigate the extent of surgical trauma stress, reduce the incidence of postoperative complications, shorten patient recovery time previously healthy state, and achieve maximize benefit for patients. Currently, the ERAS application in the specific aspects of pancreaticoduodenectomy remains contentious. However, with the emergence of evidence-based medicine, ERAS is constantly being refined. Therefore, this article combined with ERAS guidelines and expert consensus is of great significance to deepen the research and understanding of ERAS in pancreaticoduodenectomy.