The annual Digestive Disease Week (DDW) was held in San Diego, the US, from May 21st to 24th 2016. DDW gathers digestive disease doctors and researchers around the country and the world. The topic of this year was “Catch the Next Wave in Science & Medicine”.

     Professor Miao Yi, Associate Professor Gao Wentao of the Pancreas Center of the First Affiliated Hospital of Nanjing Medical University and Professor Li Xiangcheng of the Hepatic Surgery were invited to the conference. They have given important lectures and presentations of surgery videos during the Hepatobiliary and Pancreatic Diseases Chapter of SSAT.

    In his lecture, Professor Miao Yi first briefly introduced the Pancreas Center of Nanjing Medical University. The Center is the first professional multi-disciplinary center dedicated in pancreas disease in China. More than 500 pancreatic operations and nearly 300 pancreaticoduodenectomy (PPPD) operations are conducted there. It is a top-ranking high-capacity pancreas center in China and even the world. Later, Professor Miao Yi delivered the lecture named “Pylorus Preserving Pancreaticoduodenectomy (PPPD) with Technique Modification” together with videos of surgery, and introduced multiple technological modifications in pancreaticoduodenectomy of the Center in the last decade, which not only significantly improved the success rate and quality, accelerated the process, but also lowered operative complications and facilitated the recovery of patients.

       The high-profile lecture fueled a heated debate among participants. A Japanese professor asked about the afferent loop length from pancreatic-intestinal anastomosis to gastrointestinal anastomosis. Professor Miao Yi pointed out that the shorter afferent loop is often kept in PPPD in order to avoid postoperative anastomotic ulcer. Meanwhile, the shorter afferent loop is used for gastrointestinal tube afferent loop internal decompression, lowering the risk of pancreatic fistula of high-risk patients; Professor Rory Smooth from Mayo Clinic was astonished by the ultra-fine pancreatic duct demonstrated in the video, which is merely 2mm in diameter but capable of finishing pancreaticojejunostomy at high velocity and in high quality. Professor Miao Yi introduced the improved single-layered, interrupted pancreaticojejunostomy skills. He pointed out that with the use of single-layered – interrupted suture that runs through pancreatic duct – pancreatic duct, the 2mm pancreatic duct does not necessarily needs a stent, and the process can be finished in just 10 minutes (it takes 30 minutes for the European Pancreas Center in Heidelberg, which is the world’s largest center in the area of pancreatic diseases, to finish a pancreaticojejunostomy). Not only is it a rapid method with low recent pancreatic fistula rate, but it also perfectly turns the pancreatic-intestinal anastomosis into a mucosa, avoiding long-term pancreatic-intestinal anastomotic stenosis. A Canadian professor also had further discussions with Professor Miao Yi regarding pancreaticojejunostomy techniques. Professor Miao pointed out the essence of pancreaticojejunostomy, which is from “mechanical connection” to “biological healing”. The improved “single-layered pancreaticojejunostomy” highlights the blood supply to pancreas, avoids cutting extra sutures. The anastomosis is firm and biological healing is easier.

      As the first lecturer of surgery video unit of the Pancreatic Disease Session of DDW, Professor Miao Yi’s lecture contained his profound understanding in the essence of pancreatic operations. Each improving technique has been well-thought and well-tempered. The wonderful lecture drew a prolonged applause.

      The first topic of Professor Li Xiangcheng from the Hepatic Surgery was “Anterior Approach Right Hepatectomy Combined with Inferior Vena Cava Thrombectomy Using Trans-Diaphragmatic Intrapericardium IVC Occlusion”. According to AALSD, EASL and BCLC, Sorafenib is recommended for the therapy of hepatoma patients with aortic complications. For hepatoma patients who have aortic thrombi and aortic complications, should they be recommended with surgical treatment? A few reports in the world showed that radical excision may improve the median survival time of patients. The huge hepatoma in the right lope with vena cava thrombi higher than diaphragm was mentioned in the report. Regular surgical methods may find it difficult to process radical excision, and intraoperative extrusion may lead to the fall-off of vena cava thrombi, leading to possible PTE, sudden death or pulmonary metastasis. Anterior approach right hepatectomy was adopted in this case without making contact with the tumor and thrombi, dividing the liver parenchyma to vena cava. After vena cava and RHV are fully exposed, SVC is occluded atop vena cava thrombi via diaphragm and pericardial cavity. Meanwhile, THVE is conducted which includes hepatic portal occlusion and infra-hepatic IVC occlusion. Then, RHV is scissored, and the Thrombi Peeling-Off technique is adopted for complete excision of the right liver lobe and thrombi. According to postoperative follow-up, the patient remains alive for one year and a half and in good conditions. The lecture was well-received and caused heated discussion among experts. Professor Rory Smooth from Mayo Clinic raised a question about how to precisely determine the location of thrombi, and will intra-operative B-scan ultrasonography be used? For patients of complicating hepatic cirrhosis, how do they prevent postoperative hepatic failure? Professor Li Xiangcheng has provided answers to each of his question.

    The second topic of Professor Li Xiangcheng’s report was “Anterior Hepatic Parenchymal Transection for Isolated Caudate Lobectomy”. Caudate lobectomy is an extremely challenge operation clinically since the anatomical position is deeper and adjacent to peripheral aorta. Operative approaches are designed based on different positions. The caudal lobe tumor mentioned in this case is located in LHV, MHV and RHV and IVC treatment, and atop right and left bifurcations of hepatic pedicle of the first hepatic portal. Anterior approach is adopted for complete split of liver parenchyma so that the relations between tumor and LHV, MHV, RHV and IVC can be fully exposed, making the operation become safe and controllable. Such technique has aroused the interest of and caused heated debate among participants. Professor Jean-Nicolas Vauthey from MD Anderson strongly endorsed our modus operandi. Professor Zenichi Morise from Fujita Health University and Professor Shimul Shah from University of Cincinnati had discussions regarding how to obtain negative incisal margin, how to deal with complicating MHV, and whether the complicating hemihepatectomy is necessary. Meanwhile, Professor Li Xiangcheng told the audience that a total of more than 6,000 hepatectomy cases, 1,000 liver transplant cases and 200 hilar cholangiocarcinoma cases were conducted in the Pancreas Center of the First Affiliated Hospital of Nanjing Medical University. The five-year survival rate of primary hepatic carcinoma patients is above 50%, and the five-year survival rate of hilar cholangiocarcinoma patients is 25%. Previously, Professor Li Xiangcheng has had exchanges in IHBPA 2016 and ILTS.

    Associate Professor Gao Wentao of the Pancreas Center delivered the lecture named “Laparoscopic Pancreaticoduodenectomy with Posterior and Uncinate Process First Approach” and presentation of surgery video. He proposed that the angles and advantageous visual field of laparoscope shall be flexibly and fully used in laparoscopic pancreaticoduodenectomy. With “uncinate process first approach, posterior approach and arterial first approach”, the main vessels hidden behind pancreas and those deep in mesentery can be clearly and directly exposed in vision, and peripheral lymphatic nerve tissues can be completely removed, finishing the skeletonization of superior mesenteric artery, celiac trunk, and hepatic artery etc., improving the dissection range and quality of the lymphatic nerve tissues of pancreatic carcinoma. As the case shown in the video, a pancreatic carcinoma patient whose tumor diameter is merely 1.5cm had 8 cancerometastasis cases after a dozen of the patient’s lymph glands were dissected, which further proved the necessity of lymph node dissection. The expanded lymph node dissection is finished with the use of uncinate process first approach and arterial first approach, which will lower local recurrence rate, and improve prognosis; Professor Rory Smooth from Mayo Clinic showed concerns in terms of the time consumption and pancreatic fistula rate of minimally invasive pancreatic operation. Associate Professor Gao Wentao pointed out that the average time consumption is currently 480 minutes, but dissection and reconstruction quality is not lower than that of an open operation. Professor Zenichi Morise from Fujita Health University suggested that the Pancreatic Surgery Department of his university is currently capable of laparoscopic pancreatic body and tail excision. But they’ve thinking about laparoscopic pancreaticoduodenectomy. Doctor Shakya from India showed his interest and expressed his willingness to visit the Pancreatic Center.

       As Professor Miao Yi said, the features and advantages of laparoscope should be used together in minimally invasive laparoscopic pancreatic operations, and approaches differ from open operation are used. Uncinate process first approach and arterial first approach can be perfectly matched with laparoscopic operations. The advantages of minimal invasion and good operation quality benefit patients a lot, which will be the development trend of pancreatic operations in the future.