Duct Size Research Articles

Use of histomorphological features for the prediction of grade C fistula after Whipple procedure – a difficult task

Introduction The prediction of occurrence and form of a postoperative pancreatic fistula (POPF) could decrease the risk after pancreatic resections. We developed a score based on histomorphological criteria to predict POPF earlier on. In this study we test the scoring system to differentiate between patients developing grade B and C postoperative pancreatic fistula. Methods We analysed 92 patients who underwent pancreatic head resection and developed a grade B or C POPF postoperatively. There were no exclusion criteria. Pancreatic resection margins were analysed histologically and pancreatic duct size, fibrosis, fat content and signs of inflammation were transformed into a scoring system. Results Patients with a grade B fistula (n=48) were compared to patients with grade C fistula (n=44). Grade C group was characterized by higher mortality (0 vs 22, p<0.001), postpancreatectomy haemorrhage (3 vs 24, p<0.001) longer stays in ICU (2.6 vs 21.1, p<0.001) and in hospital (29.8 vs 44.6, p<0.001). The scoring system was unable to predict grade C fistula. We calculated receiver operator characteristics for all assessed characteristics, which revealed an area-under-the-curve of 0.561. The strongest predictors of POPF grade C were pancreatic fat and soft pancreatic tissue. A combination of only these two items led to a statistically significant difference (p<0.001) and an AUC of 0.771. Conclusion Establishing a score to differentiate between grade B and grade C POPF is a difficult task. Pancreatic fat seems to be the most relevant histomorphological feature to be used in any scoring system and it should be combined with other clinical features to enhance its precision and validity.

Tight Anastomosis of the Pancreatojejunostomy During Pancreatoduodenectomy May Cause Late Acute Pancreatitis.

To investigate risk factors of late acute remnant pancreatitis after pancreatoduodenectomy (PD), we propose the use of a suturing pitch calculated based on the diameter of the main pancreatic duct and the number of sutures used in the pancreatic duct-to-mucosa anastomosis. This study aimed to determine whether the suturing pitch can predict late acute pancreatitis following PD. This study included 142 patients who underwent elective PD. The suturing pitch was defined as the distance between the ligations of the duct-to-mucosa anastomosis of the pancreatojejunostomy. It was calculated using the formula: main pancreatic duct size × π ÷ suturing number. Late acute pancreatitis was defined as acute pancreatitis occurring more than 30 days after PD. We retrospectively evaluated clinical parameters, including the suturing pitch, to identify predictors of late acute remnant pancreatitis. Late acute remnant pancreatitis occurred in seven patients, and the 5-year and 10-year cumulative incidence rates were 8.5% and 12.7%, respectively. A narrow suturing pitch was significantly associated with male sex (p=0.037), younger age (p=0.003), soft pancreas (p<0.001), narrow pancreatic duct stent size (p<0.001), narrow main pancreatic duct size (p<0.001), and the occurrence of late acute remnant pancreatis (p=0.006). In multivariate analysis, the narrow suturing pitch was a significant and independent risk factor of late acute remnant pancreatitis (p=0.041), but not of postoperative pancreatic fistula (p=0.106). To prevent late acute remnant pancreatitis, the pancreatic duct-to-mucosa anastomosis should not be sutured too tightly.

Impact of single layer reconstruction following surgery for chronic calcific pancreatitis: a retrospective analytical study

Background: Surgery is an effective treatment for chronic calcific pancreatitis (CCP), addressing intractable pain and complications. While many studies predict outcomes of various surgical procedures, few focus on the impact of reconstruction type. This retrospective study analyzed the outcomes of single-layer pancreaticojejunostomy (PJ) following surgery for CCP. Aim was to evaluate outcomes of single-layer PJ in CCP patients, focusing on complications, pain relief, exocrine insufficiency, and endocrine dysfunction, compared with historical controls. Methods: The study included 250 CCP patients treated at a tertiary care center in Chennai, India, from January 2011 to December 2024. Surgical ductal clearance and single-layer Roux-en-Y PJ using non-absorbable/delayed absorbable sutures were performed. Data on intraoperative parameters, postoperative complications, and follow-up assessments at 1, 2, and 3 months were analyzed. Primary outcomes included reductions in pancreatic fistula, bleeding, and infections. Secondary outcomes included operative time and duct size. Results: The median age was 38 years, with a male predominance (74%). Frey’s procedure was the most common (59.2%), and the mean operative time was 170 minutes. Complications included pancreatic fistulas (6.4%) and infections (9.6%), with a low mortality rate (0.4%). Postoperatively, 91% of patients achieved pain relief, and 64.4% of diabetics had improved glycemic control. Single-layer PJ showed shorter operative times than two-layer PJ with similar pain relief and blood loss. Complications decreased significantly (from 45% to 8%), alongside reduced postoperative pain scores. Conclusions: Single-layer PJ is a safe, effective reconstruction method for CCP, reducing surgical complexity and related complications.

External Validation of the ISGPS Complexity Grading System for Minimally Invasive Pancreatoduodenectomy: Insights from the IGOMIPS registry.

To validate the ISGPS complexity grading system for minimally invasive pancreaticoduodenectomy (MIPD). Although concerns about patient safety persist, MIPD is gaining popularity. The ISGPS recently introduced a difficulty grading system to improve patient selection by aligning procedural complexity with surgeon and center expertise. Data from MIPD cases reported in the IGOMIPS registry (October 2019-February 2024) were analyzed, with severe postoperative complications as the primary outcome. Logistic regression was used to identify risk factors for complications. Of the 771 MIPD cases, 426 (55.3%) were analyzed. A pancreatic duct size ≤3mm was the only significant risk factor for severe complications (OR=2.22, P=0.0001). Most cases (n=255; 59.9%) were classified as grade C complexity, whereas 22 (5.1%) were classified as grade A. Severe postoperative complications increased with complexity (grade A, 31.8%; grade B, 36.3%; grade C, 48.6%; P=0.0091). For grade A complexity, the outcomes were consistent across surgeons and centers. Grade B outcomes were similar between grade B and C centers but superior to grade A centers. In grade C cases, outcomes were comparable between grade A and B centers, with improvements at grade C centers. Grade A ISGPS experience correlated strongly with mismatches between planned and performed procedures (grade A, 15.0%; grade B, 3.0%; grade C, 3.1%; P<0.0001), including total pancreatectomy (grade A, 11.5%; grade B, 1.2%; grade C, 3.1%; P=0.0005). The ISGPS complexity grading system effectively predicted MIPD outcomes, supporting better patient selection and alignment of complexity with surgical expertise.

Biliary sphincterotomy resets pancreaticobiliary pain refractory to intrasphincteric Botox injections in functional biliary pain.

The management of Type III sphincter of Oddi dysfunction or functional biliary pain (FBP) is challenging. A strategy of intermittent intrasphincteric botulinum toxin (Botox) injections into the sphincter of Oddi can alleviate pancreaticobiliary pain. In patients who lose response to intermittent Botox injections, endoscopic biliary sphincterotomy (ES) could potentially reset pain facilitating ongoing management of symptoms. A retrospective review of case notes over a seven-year period (2014-2021) was performed. All patients underwent blood tests, gastroscopy, trans-abdominal ultrasonography, cross-sectional imaging withmagnetic resonance cholangiopancreatography (MRCP)/computed tomography (CT) and endoscopic ultrasound (EUS)to rule out alternative causes for their symptoms of pancreaticobiliary pain. A diagnosis of FBP was made in patients with typical post-cholecystectomy pain and normal liver function tests and bile duct size on imaging. Patients with symptomatic FBP underwent intermittent endoscopic Botox injections to the sphincter of Oddi. Patients who lost response to Botox injections underwent ES and were followed up in an outpatient setting to assess response. One hundred and thirty (128 female, 2 male) patients with FBP underwent a mean of four (2-8) Botox injections over the study period. Of 130 (90%) patients, 117 reported a significant improvement in pain on post procedure review with 81% of patients managing to discontinue opioid medication post procedure. Fifty-one out of 130 (39%) lost response to Botox injections after a median of six (range 5-11) sessions (median eightmonths between sessions [range 6-18months]) and continued to have ongoing pancreaticobiliary pain and subsequently underwent biliary ES. Forty-one out of 50 (82%) reported a clinical improvement in their symptoms of pancreaticobiliary pain following ES, with response persisting at follow-up for up to mean of eight (5-15) months and no further hospital attendances due to severe pancreaticobiliary pain. ES can reset pancreaticobiliary pain in FBP once Botox injection therapy to the sphincter of Oddi becomes ineffective and may provide ongoing relief of symptoms.

Comparison between pancreatojejunostomy and pancreaticogastrostomy in pancreaticoduodenectomy in a gastroenterology and hepatology teaching hospital

Background: Pancreatoduodenectomy (PD) is a surgical procedure used to treat diseases of the pancreatic Head, the distal common bile duct (CBD), and the duodenum, as well as trauma to the head of the pancreas. Once the pancreatic head and the duodenum are resected, the surgeon needs to reconnect the stomach, the biliary tract, and the pancreatic stump. The technique for reconstructing the biliary tract is fairly standard, represented by the anastomosis of the CBD to the jejunum, but the reconstruction of the pancreatic stump is a matter of debate. In general, two procedures can be used: pancreaticojejunostomy (PJ), which is an anastomosis between the pancreatic stump and the jejunum, and pancreaticogastrostomy (PG), which is an anastomosis between the pancreatic stump and the stomach. Aim: The objective of this study was to compare the impact of PJ and PG on the occurrence of postoperative pancreatic fistula (POPF), morbidity, and mortality following PD. Patients and Methods: This study took place between April 1, 2021 and April 1, 2023 at Gastroenterology and Hepatology Teaching Hospital in Baghdad Medical City. The cases in the study were designed prospectively. It is a comparison between PG and PJ after undergoing Whipple surgery. A total of 30 patients were selected and divided into two groups. The first group consisted of 16 patients who underwent PJ, while the second group consisted of 14 patients who underwent PG. The cases were prepared in the surgical consultation clinic. On the one hand, through PG, it was determined whether the texture of the pancreas was soft and the size of the main pancreatic duct (MPD) was less than 3 mm. On the other hand, through PJ, it was determined whether the texture of the pancreas was firm or hard and the size of the MPD was more than 3 mm. Results: The age group of males and females ranged from 11 to 68 (median 57) years. There were a total of 16 males and 14 females. The ampullary tumor was present in 11 patients of the PJ group and 7 patients of the PG group. Histopathology of tumors showed adenocarcinoma in 13 patients of the PJ group and in 6 patients of the PG group. POPF occurred in 3 patients of the PJ group, type A in 1 patient and type B in 2 patients, and no POPF was observed in the PG group. Hemorrhage occurred in 1 patient of the PG group and 2 patients of the PJ group. Delayed gastric emptying occurred in 5 patients: 3 patients of the PJ group (type A) and 2 patients of the PG group. SSI (surgical site infection) occurred in 7 patients: 5 patients of the PJ and 2 patients of the PG group. Finally, mortality occurred in 3 patients of the PJ group. Conclusion: Pancreatic intestinal anastomosis must be tailored to the surgeon's preferences and experience level, and any innovative technique that reduces the prevalence of POPF is welcome in pancreatic surgery. PG seems to be associated with less POPF, morbidity, and mortality than PJ after undergoing Whipple surgery, especially given the soft texture of the pancreas and the size of the MPD &lt; 3 mm. Recommendations: 1. Because our study included a limited number of samples, further prospective randomized studies with larger samples are required to confirm that PG had fewer complications. 2 Surgeons should be encouraged to use PG more frequently in the future.

HPB SO38 - Assessing current pancreatic cancer reporting practice against the PACT-UK Synoptic Reporting Template: An initial clinical audit

Abstract Background In the last decade, the incidence of pancreatic cancer has increased by 9% in the UK. The gold standard for initial assessment of pancreatic cancer (or even peri-ampullary cancer) resectability is pancreatic-protocol CT scan. The PACT-UK project introduced a synoptic template for pancreatic cancer to standardise CT reporting practice across UK and enable consistent reporting of pertinent aspects of resectability status such as vascular involvement of the tumour. The aim of this audit is to assess the quality of current CT reports received by a tertiary hepato-pancreato-biliary (HPB) unit against the standards set out by PACT-UK. Method A retrospective analysis of 66 patients who underwent pancreatic resection between September 2023 and May 2024 at a tertiary HPB centre was undertaken. Patients were excluded from the analysis if they underwent resection for benign pancreatic pathology, were diagnosed with pathology other than peri-ampullary cancer or did not have a formal report of their CT scan. Initial CT scans performed at presentation and if available, subsequent up-to-date staging scan prior to surgery were assessed against the PACT-UK reporting template, in accordance with their guidance. The audit was registered with our clinical audit team (no. 11643). Results In total, 42 patients with peri-ampullary cancers were included in this audit. All patients had a reported CT scan on presentation. Additionally, 24 patients had a reported staging CT scan. The compliance (i.e. more than 90% information available) with PACT-UK reporting standards was 0% for initial presentation scans and 4.2% (n=1) for staging scans. The only staging scan with &amp;gt;90% compliance was reported using the PACT-UK template. Majority (more than 80%) of CT scan reports lacked information on aspects such as pancreatic duct size, predicted tumour type and radiological stage, variant vascular anomalies, and arterial/venous involvement. Conclusion This audit highlights the substandard quality of current CT reporting for peri-ampullary cancer. There is an urgent need to adopt a structured and dedicated reporting template to address the issue. Utilising a template such as the one developed by PACT-UK will help ensure that relevant information is formally reported to facilitate optimal decision-making at MDT meetings, and assist surgeons in operative planning and oncologists in assessing treatment response.

Laparoscopic pancreatoduodenectomy is safe for the treatment of pancreatic ductal adenocarcinoma treated by chemoradiotherapy compared with open pancreatoduodenectomy: A matched case-control study

Few studies compared laparoscopic and open pancreatoduodenectomy for pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy. Retrospective cohort of patients who underwent laparoscopic or open pancreatoduodenectomy for resectable or borderline resectable pancreatic ductal adenocarcinoma after chemoradiotherapy between 2012 and 2023 was analyzed. Open pancreatoduodenectomy patients could theoretically benefit from the laparoscopic approach. We used a 1:2 (laparoscopic-to-open pancreatoduodenectomy) propensity score matching analysis stratified on age, gender, and body mass index. We included 128 patients (33 laparoscopic and 95 open pancreatoduodenectomy), and after propensity score matching, 33 laparoscopic pancreatoduodenectomy and 66 open pancreatoduodenectomy were compared. There was no difference in demographic data except for lower tobacco use in laparoscopic pancreatoduodenectomy group (9% vs 30%, P=.023) with similar clinical presentation. Laparoscopic pancreatoduodenectomy compared to open pancreatoduodenectomy showed a longer median operative duration (380 vs 255 minutes, P < .001), shorter median length of resected vein (15 vs 23 mm, P=.01), longer median venous clamping time (29 vs 15 minutes, P=.005), similar median blood loss (300 vs 300 mL, P=.223), similar rate of hard pancreas (97% vs 85%, P=.094), and a larger median size of Wirsung duct (5 vs 4 mm, P=.02). Postoperative outcomes showed similar 90-day mortality rates (3% vs 3%, P > .99), Clavien-Dindo III-IV complications (6% vs 14%, P=.158), median lengths of hospital stay (12 vs 13 days, P=.409), and readmission rates (9% vs 18%, P=.366). Pathologic data showed similar R0 resection rates (88% vs 82%, P=.568). With a similar rate of adjuvant chemotherapy (P= .324) and shorter median follow-up with laparoscopic pancreatoduodenectomy (18 vs 34months, P=.004), 3-year overall (P=.768) and disease-free (P=.839) survival rates were similar. In selected patients, laparoscopic pancreatoduodenectomy for pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy appears to be safe and feasible when performed in experienced centers.

Seismic Performance of Precast Drift-Hardening Concrete Walls Connected by Grout-Sheath Duct.

In order to find a suitable size of sheath duct and a reliable construction method for precast walls, a cast-in-place and five 1/2 scale precast drift-hardening concrete walls reinforced with weakly bonded ultra-high strength SBPDN rebars were fabricated and tested under reserved lateral load and constant compression. The experimental variables were the diameter of sheath ducts (45 mm, 100 mm, and 120 mm), embedded length (20d and 35d; d is the nominal diameter of SBPDN rebars), axial load ratio (0.075 and 0.15), and the construction method. The experimental observations, hysteresis behaviors, envelope curves, residual deformation, crack propagation, and energy dissipation were compared in the study. Moreover, a formula was applied to calculate the bond strength of the sheath duct. The experimental and calculated results revealed that increasing the axial load ratio and embedment length could not enhance the bond strength of the sheath ducts, and increasing the diameter decreased the bond strength significantly. Anchored the SBPDN rebars in smaller sheath ducts separately was a more stable connection method for precast concrete shear walls and provided sufficient drift-hardening capability, even at a large drift level (over 3%).

Proposal of a revised 3-tier "2mm" risk classification model for postoperative pancreatic fistula in robotic pancreatoduodenectomy.

The recent International Study Group for Pancreatic Surgery (ISGPS) risk classification for postoperativepancreatic fistula (grade B/C) was developed based on data from open and mixed minimally invasive pancreatoduodenectomy. The ISGPS risk classification model has not been validated specifically for POPF after robotic pancreatoduodenectomy (RPD). We calculated the rate of POPF (ISGPS 2016 definition, grade B/C) by analyzing consecutive patients after RPD by surgeons after their learning curves (80 RPDs per surgeon). The validation of the ISGPS 4-tier and the simplified 3-tier risk classification was conducted using the area under the receiver operating curve (AUC). From 2019 to 2023, 187 patients after RPD were included. Neither the ISGPS 4-tier nor the simplified 3-tier classification model showed robust discrimination (AUC: 0.696 and 0.685, respectively). Moreover, both risk classifications failed to differentiate the rates of POPF and major complications among subgroups. Multivariate analysis suggested that soft pancreatic texture and pancreatic duct ≤ 2mm were independent risk factors for POPF after RPD. After adjusting the duct size's cutoff from 3 to 2mm, the revised 4-tier "2mm" classification model showed no significant difference between risk categories B and C (6.7% vs. 9.4%, P = 0.063). The revised 3-tier "2mm" classification model stratified patients into A (n = 54), B (n = 68), and C (n = 65) groups, with corresponding POPF rates of 0.0%, 8.8%, and 23.1% (P < 0.001), and major complication rates of 5.6, 14.7, and 24.6% (P = 0.014), respectively. Compared to the simplified 3-tier classification model, the revised 3-tier "2mm" classification model showed improved discrimination (AUC: 0.753 vs. 0.685, P = 0.034) and clinical utility. The current ISGPS 4-tier and the simplified 3-tier classification models lacked sufficient discrimination in patients after RPD. We propose a revised 3-tier "2mm" risk classification model for RPD with a robust discrimination, which requires further international validation with prospectively obtained data.

Accurate measurement of key structures in CBD patients using deep learning

Accurate measurement of key structures in CBD patients using deep learning

Technical refinements to reduce the early biliary complication in living donor liver transplantation

Technical refinements to reduce the early biliary complication in living donor liver transplantation

Whistle while you ductwork: Predicting air leakage noise

Improperly sealed ductwork creates system inefficiencies and noise. When leaky ducts are exposed to occupied spaces, these radiated noises can be a significant nuisance as their characteristic is often hissy, tonal, and whistle-like. This presentation will offer an empirical method for predicting noise resulting from air leakage. The algorithm only requires knowledge of the duct velocity and size. Example scenarios and limitations of the method will be presented.

Preliminary testing for ASHRAE research project 1919: The effects of duct size and aspect ratio on flow noise in elbows

The goal of RP-1919 is to investigate the regenerated noise and breakout noise of elbow fittings, eventually resulting in an algorithm for a variety of flow rates that considers a duct’s size and aspect ratio. This algorithm is intended for more accurate noise prediction of elbow fittings, to better inform building design. The practical application of this project necessitates a test method that is applicable to real-world building systems. Sound intensity measurements are a logical choice to investigate the elbow fittings, with one notable challenge: differentiating airflow noise from elbow fitting noise, especially at high flow rates that an intensity probe would not typically accommodate. Preliminary testing has been done to investigate the use of a blimp style windscreen and faux-fur muff with intensity scanning; this windscreen configuration can be seen used in film and TV production to get high quality audio where extreme conditions may affect sound. This presentation will discuss initial findings from the windscreen investigation.

Risk factors for acute pancreatitis after endoscopic retrograde cholangiopancreatography: a retrospective single-center study

Background. Endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure in the diagnosis and management of pancreaticobiliary diseases. Post-ERCP pancreatitis (PEP) is the most common and serious adverse event after ERCP. Purpose – to evaluate retrospectively PEP incidence and to identify independent risk factors of PEP. Materials and Methods. The analysis of 578 ERCP cases was done. A number of potential risk factors for PEP were taken into uni- and multivariate analisys: age, gender, common bile duct (CBD) size, bilirubin level, presence of cholangitis, Sphincter of Oddi dysfunction (SOD), malignant biliary obstruction, chronic pancreatitis, biliary obstruction, history of cholecystectomy, history of endoscopic papillosphincterotomy (EPST), initial ERCP success, therapeutic success, selective biliary cannulation, pancreatic cannulation/injection, Precut and EPST. Results. PEP was in 29 (5%) cases. Six factors with р &lt; 0,05 by univariate analysis (CBD ≤ 10 mm, normal bilirubin level, SOD, history of cholecystectomy, pancreatic cannulation/injection, precut) were included into multivariate logistic regression model. The independent risk factor for PEP were CBD ≤ 10 mm (OR 2,416; 95% ДІ, 1,037–5,629; p = 0,041), SOD (OR 4,107; 95% ДІ, 1,726–9,771; p = 0,001) та pancreatic cannulation/injection (OR 3,447; 95% ДІ, 1,455–8,166; p = 0,005); and precut was an independent protective factor for PEP (OR 0,129; 95% ДІ, 0,047–0,354; p = 0,014). Conclusions. The incidence of PEP was 5%. Small CBD and SOD are independent PEP risk factors as well as pancreatic cannulation/injection. Early precut technique is an independent factor preventing PEP.

Dunking Pancreaticojejunostomy With Braun's Jejunojejunostomy: Perioperative Outcomes of a Hundred Pancreaticoduodenectomies.

Background The optimal surgical technique for pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD) is still debated. Dunking and duct-to-mucosa PJ are the most commonly adopted techniques. Incorporating Braun's jejunojejunostomy (JJ) could reducetheincidence and severity of delayed gastric emptying (DGE). This retrospective descriptive study seeks to clarify the outcomes of dunking PJ with Braun's JJ in 100 PD patients. Methodology We retrospectively reviewed 100 patients who underwent PDs in a single unit of the Department of Surgical Gastroenterology of Tribhuvan University Teaching Hospital from October 2012 to February 2023. Demographic and historical data, indications, procedure-related data, complications, and mortality data were collected and analyzed. Results The mean age was 50.96 ± 14.97 years, and 64 (64%) were males. The most common indication was ampullary carcinoma (53, 53%) followed by distal cholangiocarcinoma (18, 18%) and pancreatic ductal adenocarcinoma (7, 7%). Operative time was 5.83 ± 1.09 hours, intraoperative blood loss was 515 ± 194 mL, and the average time for PJ and Braun's JJ was 22 ± 6 and 15 ± 3 minutes, respectively. Soft pancreas was encountered in 52 (52%) patients and clinically significant postoperative pancreatic fistula (Grade B, C) was seen in 23 (23%). Postpancreatectomy hemorrhage was seen in 21 (21%) patients (Grades A: 3, B: 12, C: 6). DGE (Grade B) occurred in two (2%) patients, and bile leak was observed in 4% of patients (Grades A: 1, B: 2, C: 1). Major complications (Clavien-Dindo ≥IIIA) occurred in 24%, and 11 patients died. Conclusions The dunking technique is easily adaptable, less time-consuming, and can be performed in the pancreas of any texture or duct size but is associated with an increased incidence of post-pancreatectomy hemorrhage. Incorporation of Braun's anastomosis lowers DGE, allows early initiation of feeding, and reduces complication rates.

Risk factors for biliary strictures and leaks after living-donor liver transplantation: a systematic review and meta-analysis

Liver transplantation is the only curative treatment of end-stage liver disease. Unfortunately, a significant number of patients on the organ waitlist die waiting for an organ. Living-donor liver transplantation (LDLT) is an approach that has been used to expand organ availability. Although LDLT has excellent outcomes, biliary complications remain a significant drawback. This meta-analysis aimed to precisely assess the predictors of biliary stricture and leak after LDLT. PubMed, Embase, and Web of Science databases were searched from inception to January 2024. Only studies that used a multivariate model to assess risk factors for post-LDLT biliary stricture or leak in adult participants were included. Studies reporting unadjusted risk factors were excluded. Pooled adjusted odds ratios (ORs) and pooled hazard ratios (HRs) with 95% CIs for risk factors reported in ≥2 studies were obtained within a random-effects model. Overall, 22 studies with 9442 patients who underwent LDLT were included. The post-LDLT biliary stricture rate was 22%, whereas the post-LDLT biliary leak rate was 14%. In addition, 13 unique risk factors were analyzed. Postoperative bile leak (OR, 4.10 [95% CI, 2.88-5.83]; HR, 3.88 [95% CI, 2.15-6.99]) was the most significant predictor of biliary stricture after LDLT. Other significant predictors of biliary stricture after LDLT were right lobe graft (OR, 2.56; 95% CI, 1.23-5.32), multiple ducts for anastomosis (OR, 1.62; 95% CI, 1.08-2.43), ductoplasty (OR, 2.07; 95% CI, 1.36-3.13), ABO incompatibility (OR, 1.45; 95% CI, 1.16-1.81), and acute cellular rejection (OR, 4.10; 95% CI, 2.88-5.83). Donor bile duct size (HR, 0.82; 95% CI, 0.74-0.91; P=.001, I2 = 0%) was found to be significantly associated with reduced risk of post-LDLT biliary stricture. Donor age, recipient age, recipient male sex, and duct-to-duct anastomosis were not associated with an increased risk of post-LDLT biliary strictures. Multiple ducts for anastomosis (OR, 1.86; 95% CI, 1.43-2.43) was a significant predictor of post-LDLT biliary leak. Recipient age, warm ischemia time, and duct-to-duct anastomosis were not associated with an increased risk of post-LDLT biliary leak. In this meta-analysis, 7 unique risk factors were shown to be predictive of post-LDLT biliary stricture, one of which was associated with both post-LDLT biliary stricture and leak. Donor bile duct size was found to be protective against post-LDLT biliary strictures. Identifying reliable predictors is crucial for recognizing high-risk patients. This approach can facilitate the implementation of preventive measures, surveillance protocols, and targeted interventions to reduce the incidence of biliary strictures after LDLT.

Prospective multicenter surveillance study of branch-duct intraductal papillary mucinous neoplasm of the pancreas; risk of dual carcinogenesis

The natural history of branch-duct intraductal papillary mucinous cystic neoplasms (BD-IPMNs) in the pancreas remains unclear. This study aimed to answer this clinical question by focusing on the development of concomitant pancreatic ductal adenocarcinomas (cPDAC). The Japan Pancreas Society conducted a prospective multicenter surveillance study of BD-IPMN every six months for five years. The primary endpoints were progression of BD-IPMN, progression to high-grade dysplasia/invasive carcinoma (HGD/IC), and cPDAC. Factors predicting the progression of BD-IPMN to HGD/IC and development of cPDAC were also assessed as secondary endpoints. Among the 2104 non-operated patients, 348 (16.5%) showed progression of primary BD-IPMN. Cumulative incidences of BD-IPMN with HGD/IC and cPDAC during the 5.17-year surveillance period were 1.90% and 2.11%, respectively, and standard incidence ratios of BD-IPMN with HGD/IC and cPDAC were 5.28 and 5.73, respectively. Of 38 cPDACs diagnosed during surveillance, 25 (65.8%) were resectable. The significant predictive characteristics of BD-IPMN for progression to HGD/IC were larger cyst size (p=0.03), larger main pancreatic duct size (p<0.01), and mural nodules (p=0.02). Significant predictive characteristics for the development of cPDAC were male sex (p=0.03) and older age (p=0.02), while the size of IPMN was not significant. Careful attention should be given to "dual carcinogenesis" during BD-IPMN surveillance, indicating the progression of BD-IPMN to HGD/IC and development of cPDAC distinct from BD-IPMN, although the establishment of risk factors that predict cPDAC development remains a challenge (UMIN000007349).

Visibility and Size of the Pancreatic Duct and Common Bile Duct on Routine 2D MRI Sequences in Children Without Pancreaticobiliary Disease.

BACKGROUND. Pancreatic duct (PD) or common bile duct (CBD) dilatation can indicate ductal pathology, but limited data describe normal pediatric duct measurements on routine 2D MRI sequences. OBJECTIVE. The purpose of this study was to characterize the visibility and diameter of the PD and CBD on 2D MR images in children without pancreaticobiliary disease. METHODS. This retrospective study included patients who underwent abdominal MRI using a rapid protocol (composed of noncontrast axial and coronal 2D SSFSE sequences) to assess for suspected appendicitis or ovarian torsion in the emergency department setting between January 23, 2023, and September 13, 2023, and excluded patients with a pancreatic or hepatobiliary abnormality on MRI or laboratory assessment. Four pediatric radiologists independently reviewed examinations. Reviewers recorded PD visibility in each of four segments (i.e., head, neck, body, and tail) and CBD visibility, and reviewers measured PD diameter in each segment and maximal CBD diameter. Duct measurements by age were characterized by linear regression analyses. RESULTS. The study included 177 patients (112 female patients, 65 male patients; mean age, 12.3 ± 3.4 [SD] years [age range, 5.1-17.7 years]). The observers reported PD visibility in the head in 35.6-94.9% of patients, neck in 18.6-72.3%, body in 22.6-89.8%, and tail in 7.3-26.0% and reported PD visibility in all four segments in 6.2-22.6% of patients. Maximum PD diameter in any segment, as a mean across observers, was 1.8 mm (range across observers, 0.7-3.5 mm). The expected maximal PD diameter in any segment, in terms of the 5th and 95th percentile values of observers' mean measurements, was 1.4-2.3 mm; the prediction interval's upper limit increased from age 5 to age 17 from 2.1 to 2.5 mm. All observers reported CBD visibility in all patients. The mean CBD diameter across observers was 3.1 mm (range across observers, 2.9-3.4 mm). The expected CBD diameter, in terms of the 5th and 95th percentile values of observers' mean measurements, was 2.3-4.9 mm; the prediction interval's upper limit increased from age 5 to age 17 from 3.9 to 5.0 mm. CONCLUSION. We report expected upper limits for PD and CBD measurements on 2D MR images in children without evidence of pancreaticobiliary disease. CLINICAL IMPACT. These findings may aid radiologists' identification of pancreaticobiliary duct abnormalities on routine abdominal MRI examinations.

Calculation method for the dynamic temperature distribution of winding area in dry-type on-board traction transformer

Calculation method for the dynamic temperature distribution of winding area in dry-type on-board traction transformer