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Heparin-induced thrombocytopenia thrombosis (HITT) is a rare and potentially life-threatening complication after abdominal surgery, and it always occurs after the prophylactic or therapeutic use of heparin. HITT after pancreaticoduodenectomy (PD) has not been reported before. Herein, we reported a case of HITT after PD without prophylactic or therapeutic use of heparin. A 74-year-old female patient who suffered resectable pancreatic head cancer was transferred to our center for surgery. An open PD procedure was performed, and the operation was smooth. No heparin was used after surgery. Nine days after surgery, the platelet sharply declined to 48 × 109/L (100–350), and the D-dimer soared up to 33.56 mg/L (0–0.55). Ultrasound examination showed vein thrombosis in both the lower limb and the right upper limb. HIT-antibody was 6.3 U/mL (0–0.6). The diagnosis of HITT was confirmed. Fondaparinux was used. On postoperative day (POD) 23, the platelet recovered to the normal range. On POD 27, she was discharged without thromboembolism or active bleeding, and oral rivaroxaban was prescribed. One month after discharge, the platelet remained normal, and she did not complain of discomfort.

Background: There are limited data on the effect of different sutures and surgical approaches on the quality of pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy (MIPD). This study compares the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) between the use of barbed sutures (BSs) and conventional sutures (CSs). Methods: A retrospective cohort study was conducted on 253 consecutive patients who had undergone MIPD from July 2016 to April 2023. Patients were excluded if conversion to open surgery or open anastomosis was necessary. 220 patients were enrolled and divided into BS (n= 148) and CS (n= 72) groups. After 1:1 propensity score matching (PSM), 67 cases remained in each group. Univariate and multivariate analyses identified factors associated with CR-POPF. Comparisons were also made between laparoscopic (LPD) and robotic (RPD) pancreaticoduodenectomy. Results: After PSM, BSs were associated with significantly lower rates of CR-POPF (7.5 vs. 22.4%, P= 0.015) and severe complications (Clavien–Dindo ≥ III) (7.5vs. 19.4%, P= 0.043). No significant differences were found in operative time, length of postoperative hospital stay, or other major morbidities. Multivariate analyses revealed BMI $\ge$\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}22 kg/m2(OR = 5.048, 95% CI: 1.256–20.287, P= 0.023) and the use of BSs (OR = 0.196, 95% CI: 0.059–0.653, P= 0.008) as the independent predictors of CR-POPF. There were no significant differences in postoperative outcomes between the LPD and RPD groups, but RPD was associated with significantly shorter operative time (402.8 min vs. 429.4 min, P= 0.015). Conclusions: In conclusion, using BSs for PJ during MIPD is feasible and has the potential to reduce CR-POPF and severe complications.

Pancreatic cancer liver metastasis is an important factor leading to dismal prognosis. The details of adaptive immune remodeling in liver metastasis, especially the role of neutrophils, remain elusive. Here, combined single-cell sequencing with spatial transcriptomics results revealed that liver metastases exhibit more aggressive transcriptional characteristics and higher levels of immunosuppression compared with the primary tumor. We identified Neutrophils_S100A12 cells as the pivotal pro-metastatic cluster, specifically distributed at the invasive front of the metastatic lesions. Mechanistically, our findings indicated that nuclear factor erythroid 2 (NFE2) is a key transcription factor regulating neutrophil phenotypic polarization. Metastatic tumors produce transforming growth factor β to activate the SMAD3 pathway within neutrophils, inducing NFE2-driven polarization. NFE2 promotes the transcription of peptidylarginine deiminase 4 by binding to its promoter, leading to the generation of neutrophil extracellular traps at the invasive front. Collectively, our data demonstrate that NFE2-driven neutrophil polarization is a potential target for anti-metastatic therapy.

Background: Few studies have evaluated the preoperative factors predicting the surgical difficulty of robotic distal pancreatectomy (RDP). This study aims to explore such factors and provide guidance on the selection of suitable patients to aid surgeons lacking extensive experience in RDP. Methods: A retrospective study was conducted on consecutive patients who underwent RDP to identify preoperative factors predicting surgical difficulty. High surgical difficulty was defined by both operation time and intraoperative estimated blood loss exceeding their median, or by conversion to laparotomy. Results: A total of 161 patients were ultimately enrolled, including 51 patients with high levels of surgical difficulty. Multivariate analysis revealed that male sex [OR (95% CI): 4.07 (1.77,9.40), p= 0.001], body mass index (BMI) ≥ 25 kg/m2OR (95% CI): 2.27 (1.03,5.00), p= 0.042], tumors located at the neck of the pancreas [OR (95% CI): 4.15 (1.49,11.56), p= 0.006] and splenic artery type B [OR (95% CI): 3.28 (1.09,9.91), p= 0.035] were independent risk factors for surgical difficulty. Regarding postoperative complications, high surgical difficulty was associated with the risk of overall complications and pancreatic fistula (grade B/C) (49.0% vs. 22.7%, p< 0.001; 39.2% vs. 19.1%, p= 0.006). Conclusion: Male sex, body mass index ≥ 25 kg/m2, tumor located at the neck of the pancreas and splenic artery type B are associated with a high RDP difficulty level. These factors can be used preoperatively to assess the difficulty level of surgery, to help surgeons choose patients suitable for them and ensure surgical safety.

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