Information
Chinese Journal of General Surgery
(Monthly, Established in March 1992)
Responsible Institution
Ministry of Education People's Republic of China
Sponsor
Central South University Xiangya Hospital
Central South University
Editing
Editorial Board of Chinese
Journal of General Surgery
(Zhongguo Putong Waike Zazhi)
Editor-in-Chief
WANG Zhiming
ISSN 1005-6947
CN 43-1213/R
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Table of Content
25 March 2021, Volume 30 Issue 3
Clinical value of prognostic index in postoperative evaluation of patients with resectable pancreatic ductal adenocarcinoma
HAN Shifeng, JIN Chunfeng, ZHU Lei
Chinese Journal of General Surgery. 2021, 30(3):  247-253.  doi:10.7659/j.issn.1005-6947.2021.03.001
Abstract ( 52 )   PDF (1069KB) ( 43 )   Save
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Background and Aims: Cancer-related inflammation is not only associated with tumor proliferation, maintenance and dissemination, but also is critical for tumor angiogenesis, adaptive immune disorders and impaired chemotherapy response. Accordingly, a number of specific score systems have been established on the basis of inflammatory markers that have been validated as prognosticators for therapy responses and outcomes in patients with solid malignancies. This study was conducted to determine the clinical value of prognostic index (PI) for long-term results in patients with pancreatic ductal adenocarcinoma (PDAC).  
Methods: The clinical data of PDAC patients who received pancreatectomy in the Panjin Liao-Oil Gem Flower Hospital from January 2011 to 2014 December were retrospectively analyzed. The PI scores were calculated via preoperative C-reactive protein levels and white blood cell counts. Among patients with different PI scores (0, 1 and 2), the differences in clinicopathologic characteristics and survival rate were compared. The risk factors for postoperative survival of PDAC patients were also determined.
Results: Of the 112 patients, 37 cases had a PI score 0, 51 cases had a score 1, and 24 cases had a score 2. There were no statistical differences in the basic data among the three groups of patients (all P>0.05). Analysis of clinicopathologic features showed that there were statistical differences among three groups of patients in terms of preoperative CA19-9 level, TNM stage and vascular invasion (χ2=10.929, 3.029, and 7.540, all P<0.05), and no significant differences were noted in tumor size, surgical method, degree of tumor differentiation, nerve invasion, postoperative complications, and postoperative adjuvant chemotherapy (all P>0.05). The follow-up time was 9–81 months, with a median follow-up time of 13 months. During the follow-up period, 103 patients died, and 9 patients survived. The results of survival analysis showed that the 5-year survival rate was decreased with the elevation of PI score (score 0:18.9%, score 1: 3.9% and score 2: 0.0%; χ2=9.195, P=0.010). Univariate analysis showed that tumor size, CA19-9 level, TNM stage, degree of tumor differentiation, PI, and postoperative adjuvant chemotherapy were significantly related to the 5-year survival rate of PDAC patients (χ2=4.881, 8.377, 15.022, 5.349, 9.195, and 4.066, all P<0.05). Multivariate analysis showed that CA19-9 >37 IU/mL (HR=1.639, 95% CI=1.073–2.506, P=0.022), TNM stage III (III vs. I: HR=2.210, 95% CI=1.229–3.974, P=0.008; II vs. I: HR=1.925, 95% CI=1.081–3.426, P=0.026) and PI score 2 (2 vs. 0: HR=2.083, 95% CI=1.190–3.645, P=0.010; 1 vs. 0: HR=1.764, 95% CI=1.101–2.828, P=0.018) were independent risk factors affecting the postoperative survival of PDAC patients.
Conclusion: PI is an independent risk factor for the postoperative prognosis of PDAC patients, and those with a higher PI may have a worse prognosis. However, evaluation in larger controlled studies is needed before introduction of PI into clinical practice as a prognostic indicator. 
Association of serum ANGPTL2 with clinicopathologic features of pancreatic cancer and its diagnostic value for pancreatic cancer
QIN Wen, CHEN Taiwen, ZHENG Haiping, YANG Jianyu, ZHU Xiaodong
Chinese Journal of General Surgery. 2021, 30(3):  254-260.  doi:10.7659/j.issn.1005-6947.2021.03.002
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Background and Aims: The onset of pancreatic cancer is insidious and most of the patients were diagnosed at an advanced stage, thus losing the chance of radical treatment. Therefore, finding a new biomarker for the diagnosis of pancreatic cancer is of great significance. This study was conducted to investigate the association of the serum angiopoietin-like protein 2 (ANGPTL2) in pancreatic cancer patients with the clinicopathologic characteristics and its application value in diagnosis of pancreatic cancer. 
Methods: Serum ANGPTL2 levels between 125 pancreatic cancer patients and 66 healthy subjects were compared. The relations of serum ANGPTL2 level with the clinicopathologic variables and CA19-9 level as well as the risk factors for pancreatic cancer were analyzed by statistical methods. ROC curve was used to analyze the diagnostic abilities of serum ANGPTL2, serum CA19-9 and their combined detection for pancreatic cancer.
Results: The average serum level of ANGPTL2 in pancreatic cancer patients was significantly higher than that in healthy individuals (6.52 ng/mL vs. 3.78 ng/mL, P<0.05). The serum ANGPTL2 level in pancreatic cancer patients was significantly related to tumor size, histological grade, lymph node metastasis and TNM stage (all P<0.05), and irrelevant to sex, age and distant metastasis (all P>0.05). There was a significant positive correlation between serum ANGPTL2 level and CA19-9 level (r=0.772, P<0.001). Univariate and multivariate analysis showed that diabetes mellitus (P=0.016) and ANGPTL2 (P=0.014) were independent risk factors for pancreatic cancer. The AUC values of serum ANGPTL2, CA19-9 and their combined detection for diagnosis of pancreatic cancer were 0.939, 0.953 and 0.966, with the specificity/positive predictive value of 92.4%/95.7%, 84.8%/91.9%, and 98.5%/96.4%.
Conclusion: Serum ANGPTL2 level is elevated in pancreatic cancer patients. The ANGPTL2 level is closely related to the clinicopathologic features. The combined detection of ANGPTL2 and CA19-9 has certain value in diagnosis of pancreatic cancer.
Expression of DEP domain protein 1B in pancreatic cancer and its clinical significance
LI Mingxu, ZHONG Chengcheng, ZHANG Gongming, HU Wei, , WANG Zhong,
Chinese Journal of General Surgery. 2021, 30(3):  261-268.  doi:10.7659/j.issn.1005-6947.2021.03.003
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Background and Aims: Previous studies have shown that DEP domain protein 1B (DEPDC1B) is abnormally expressed in a variety of tumors and plays an important role in tumor progression. However, the expression level and clinical significance of DEPDC1B in pancreatic cancer are still unclear. Therefore, this study was aimed to investigate the clinical significance of DEPDC1B in pancreatic cancer by determining the DEPDC1B expression in pancreatic cancer tissue and its association with the clinicopathologic parameters and prognosis of pancreatic cancer patients.  
Methods: The clinical data of pancreatic cancer patients were downloaded from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases, and then, the DEPDC1B expressions in pancreatic cancer tissue were analyzed, and the relation of DEPDC1B expression with the prognosis of pancreatic cancer patients was determined by Kaplan-Meier survival curve and Cox risk model. The DEPDC1B expression in 97 paired specimens of pancreatic cancer and adjacent normal tissues was detected by immunohistochemical staining, and the associations of DEPDC1B expression with clinicopathologic variables and prognosis were evaluated. 
Results: The DEPDC1B expression of in pancreatic cancer tissue was significantly higher than that in matched normal tissues in TCGA database and the GSE16515, GSE15471 and GSE28735 datasets of GEO database (all P<0.05); the survival time of pancreatic cancer patients with high DEPDC1B expression was significantly shortened in TCGA database and GSE28735 dataset; DEPDC1B expression was an independent risk factor for the prognosis of pancreatic cancer patients in TCGA database (HR=1.32, 95% CI=1.118–1.559, P=0.001). In the 97 clinical pancreatic cancer patients, the positive DEPDC1B expression rate was significantly higher in pancreatic cancer tissue than that normal tissue (69.07% vs. 11.34%, P<0.001); the DEPDC1B expression was significantly associated with the degree of differentiation, clinical stage and lymph node metastasis (all P<0.05); the overall survival of patients with high DEPDC1B expression was shorter than that of patients with low DEPDC1B expression; the DEPDC1B expression was an independent risk factor  for prognosis (HR=1.126, 95% CI=1.012–1.253, P=0.029). 
Conclusion: High DEPDC1B expression may be involved in the occurrence, development and metastasis of pancreatic cancer, and it can be used as a prognostic biomarker for pancreatic cancer patients.
Expression of NIMA-related kinase 2 in pancreatic cancer and its clinical significance
Chinese Journal of General Surgery. 2021, 30(3):  269-275.  doi:10.7659/j.issn.1005-6947.2021.03.004
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Background and Aims: The expression of NIMA-related kinase 2 (NEK2) is increased in a variety of malignant tumors, and is closely associated with tumor progression and patients’ unfavorable prognosis. However, the expression of NEK2 and its significance in pancreatic cancer are still unclear. Therefore, this study was conducted to investigate the NEK2 expression in pancreatic cancer tissue and its relationship with clinicopathologic factors and prognosis of the patients.  
Methods: The surgical specimens from 108 patients with pancreatic cancer undergoing pancreatectomy from January 2013 to December 2014 in the Department of Hepatopancreatobiliary Surgery of Hainan Provincial People's Hospital as well as the clinicopathologic and follow-up data of these patients were collected. The expressions of NEK2 in the tissue samples were detected by immunohistochemical staining. The relations of NEK2 with the clinicopathologic factors were analyzed, and the difference in tumor-free survival and overall survival rates between patients with different NEK2 expression levels were analyzed and compared by Kaplan-Meier survival curve and Log-rank analysis. The prognostic factors were determined by Cox proportional hazard model.
Results: There was no NEK2 expression in the normal pancreatic tissue, while in the 108 samples of pancreatic cancer tissue, high and low NEK2 expressions were found in 63 cases (58.3%) and 45 cases (41.7%), respectively. The NEK2 expression was significantly associated with CA19-9 level (P=0.015), TNM stage (P=0.002), tumor differentiation (P=0.034), and lymph node metastasis (P=0.043), but irrelevant to sex, age, smoking, CEA level, tumor size and tumor location (all P>0.05). The 1-, 3- and 5-year disease-free survival rates were 60.5%, 20.7% and 5.2% in patients with high NEK2 expression, and 75.4%, 50.6% and 24.9% in patients with low NEK2 expression, and the 1-, 3- and 5-year overall survival rates were 75.6%, 42.2% and 15.3% in patients with NEK2 expression, and 85.7%, 60.6% and 30.1% in patients with low NEK2 expression, respectively. Both disease-free survival and overall survival rates in patients with high NEK2 expression were significantly lower than those in patients with low NEK2 expression (both P<0.05). Univariate and multivariate analysis showed that TNM stage (P=0.029), lymph node metastasis (P=0.016) and NEK2 high expression (P=0.032) were independent influencing factors for tumor-free survival, and TNM stage (P=0.035), degree of differentiation (P=0.042), lymph node metastasis (P=0.006) and NEK2 high expression (P=0.000) were independent influencing factors for overall survival. 
Conclusion: High NEK2 expression is an independent risk factor for the prognosis of pancreatic carcinoma patients, and NEK2 can be used as an indicator for prognosis of pancreatic carcinoma patients after operation.
Identification of hub genes in pancreatic adenocarcinoma and construction of a support vector machine diagnostic classifier based on bioinformatics approaches
ZHANG Bo, XU Tao, XU Hao, XIA Yu, ZHOU Wence,
Chinese Journal of General Surgery. 2021, 30(3):  276-285..  doi:10.7659/j.issn.1005-6947.2021.03.005
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Background and Aims: Pancreatic cancer is a common malignant tumor of the digestive tract. Its main pathological type is pancreatic adenocarcinoma (PAAD). Due to the difficulty of early diagnosis and lack of effective treatment measures, the prognosis of PAAD is extremely poor. Therefore, defining new targets for the diagnosis and treatment of PAAD is of great significance. This study was conducted to screen the hub genes related to the diagnosis and prognosis of PAAD by bioinformatics analysis, and then construct a support vector machine (SVM) model to classify PAAD and normal pancreatic samples, so as to provide a useful resource for researches in terms of diagnosis, treatment and mechanism of PAAD. 
Methods: Three microarray datasets (GSE28735, GSE62165, GSE62452) were downloaded from the Gene Expression Omnibus (GEO) database. The differentially expressed genes (DEGs) between PAAD tissue and normal pancreatic tissue were screened using Limma package of R language. GO and KEGG pathway enrichment analysis of the DEGs were performed using STRING database. Then, protein-protein interaction networks (PPI) of the DEGs were generated using the STRING server and visualized by Cytoscape software. Key subnetwork module analyses were performed through MCODE plug-in. R language survival package was used to screen the key nodes related to prognosis in PPI and key subnetworks, and then, the key nodes were uploaded to Metascape for function enrichment analysis. The recursive feature elimination (RFE) algorithm in caret package of R language was used to select the optimal feature genes in key nodes, and the expression differences of the optimal feature genes were verified in GEPIA database. A SVM classifier based on the optimal feature genes was constructed using the R language e1071 package, and the R language pROC package was used to verify the model in the 3 microarray datasets. In the TCGA database, the R package survminer was used to select the genes related to the prognosis of PAAD among the optimal feature genes as the hub genes. 
Results: A total of 257 DEGs were screened, including 168 up-regulated genes and 89 down-regulated genes. GO analysis showed that DEGs were mainly involved in biological processes such as the extracellular matrix organization, cell adhesion, serine-type peptidase activity. KEGG analysis showed that DEGs were mainly enriched in protein digestion and absorption, pancreatic secretion, focal adhesion and PI3K-Akt signaling pathway. Survival analysis showed that 14 key nodes were associated with the prognosis in both GSE28735 and GSE62452 (all P<0.05), and these genes played a certain role in neoplasm invasiveness and oncogenesis. RFE screened out 8 optimal feature genes: LAMA3, FN1, ITGA3, MET, PLAU, CENPF, MMP14, and OAS2; GEPIA database validation found that the 8 optimal feature genes were significantly up-regulated in PAAD tissues (all P<0.01). The AUC of ROC curve of the SVM model constructed by these genes in the 3 microarray datasets were 0.898, 1.000 and 0.905, respectively. TCGA database verification found that the up-regulations of LAMA3, ITGA3, MET, PLAU, CENPF and OAS2 were associated with poor prognosis of PAAD (all P<0.05).
Conclusion: The hub genes LAMA3, ITGA3, MET, PLAU, CENPF and OAS2 may be new targets for diagnosis or treatment of PAAD. The SVM model based on 8 optimal feature genes offers an effective tool for diagnosing PAAD.
Effects of p38MAPK inhibitor on intestinal microbiota in rats with hyperlipidemic acute pancreatitis
LI Zhen, ZHANG Xiaoying, YANG Guodong
Chinese Journal of General Surgery. 2021, 30(3):  286-293.  doi:10.7659/j.issn.1005-6947.2021.03.006
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Background and Aims: The activation of p38MAPK signaling pathway participates in inflammatory regulation, and its inhibitor, SB203580, can suppress the secretion of inflammation-related factors, which also has been proven to lessen the damage of gastrointestinal mucosal barrier in acute pancreatitis (AP). However, the role of p38MAPK signaling pathway in intestinal inflammation and microflora imbalance in hyperlipidemic acute pancreatitis (HLP) is unclear. Therefore, this study was conducted to observe the effect of SB203580 on gut inflammation and microbiota dysbiosis in HLP model of rats, so as to provide theoretical and experimental basis for the treatment of HLP.  
Methods: Twenty-four male SD rats were equally randomized into sham operation group, model group and SB203580 group. Rats in sham operation group were fed with normal standard diet, and those in model group and SB203580 group were fed with high-fat diet for 4 weeks. After that, rats in sham operation group underwent sham operation, and those in the latter two groups underwent taurocholic acid injection into the pancreaticobiliary duct to induce AP, and rats in SB203580 group were intraperitoneally injected with SB203580 (5 mg/kg) 1 h before the model creation. At 12 h after operation, rats in each group were sacrificed and the blood and fecal samples as well as the the specimens of distal ileum and pancreatic tissues were obtained. The histopathological changes of pancreas and ileum were observed by HE staining, the contents of D-lactate and diamine oxidase (DAO) in plasma and the levels of IL-1β, TNF-α and IL-6 in the intestinal tissue were measured by ELISA assay, the expressions of p38MAPK and p-p38MAPK protein in the intestinal tissue were determined by Western blot analysis, and the changes in gut microbiota were identified by16s rDNA gene sequencing.
Results:  In model group compared with sham operation group, the pancreas and ileum showed obvious pathological damage, the contents of D-lactate, DAO, IL-1β, TNF-α, and IL-6 as well as the expressions of p38MAPK and p-p38MAPK protein were significantly increased (all P<0.05); the abundance of Bacteroidetes and Lactobacillus increased and the abundance of Akkermansia decreased (all P<0.05). In SB203580 group compared with model group, the contents of DAO, IL-1β, TNF-α and IL-6 together with the expressions of p38MAPK and p-p38MAPK protein were significantly decreased (all P<0.05); the proportion of Bacteroidetes was decreased and the abundance of Firmicuts and Akkermansia were increased (all P<0.05).
Conclusion: The p38MAPK inhibitor SB203580 can reduce gut inflammation and regulate microbiota dysbiosis in HLP model of rats.
Anti-inflammatory effect of bone marrow mesenchymal stem cells in rats with severe acute pancreatitis and its association with TLR4/NF-κBp65 pathway
QIN Yafei, HUO Xingguang, LI Qiuxia, XU Yusheng
Chinese Journal of General Surgery. 2021, 30(3):  294-304.  doi:10.7659/j.issn.1005-6947.2021.03.007
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Background and Aims: Severe acute pancreatitis (SAP) is one of the most frequently encountered serious acute illnesses in clinical practice. Inflammation plays an important role in its occurrence and development. At present, bone marrow mesenchymal stem cell (MSC) transplantation is considered having the potential to repair the pancreatic tissue injury caused by SAP, but the specific function is unclear. Therefore, this study was conducted to explore the anti-inflammatory effect of bone marrow MSC and its mechanism in SAP using SAP rat models. 
Methods: The bone marrow MSCs were isolated from the SD rats, and then were cultured and identified, and finally prepared into cell suspension with a density of 1.0×106/mL. Rat SAP models were created by retrograde injection of 3.5% sodium deoxycholate into the biliopancreatic duct. Thirty-six SD rats with successful model induction were randomly divided in four groups, and underwent intraperitoneal injection of normal saline (model group), intraperitoneal injection of MSC suspension (intraperitoneal injection group), tail vein injection of MSC suspension (tail vein injection group), or intraperitoneal injection plus tail vein injection of MSC suspension (combined injection group) at 12 h after modeling, respectively. In addition, another 9 SD rats underwent sham operation (sham operation group), and then received intraperitoneal injection of normal saline of the same volume 12 h after operation. The rats in each group were sacrificed 24 h after injection and the blood and pancreatic tissue samples were harvested. The pathological changes of pancreatic tissue were observed and the degrees of pancreatic damage were scored. The serum levels of amylase (AMS) and lipase (LPS) were measured by iodine colorimetry and methyl halide substrate methods respectively. The contents of IL-6, IL-1β and TNF-α in pancreatic tissue were detected by ELISA assay. The activity of peroxidase (SOD) was detected by hydroxylamine method, and concentration of malondialdehyde (MDA) was detected by thiobarbituric acid method. The mRNA expressions of toll-like receptor 4 (TLR4), myeloid differentiation factor 88 (MyD88), NF-κBp65 were determined by RT-PCR, and the protein expressions of TLR4, MyD88, and NF-κBp65 were examined by Western blot.
Results: The MSCs were spindle-shaped and formed whirlpool-like patterns, with low CD45 expression (1.25%) and high CD90 expression (99.89%) as well as good viability. Compared with sham operation group, in all other groups, the pancreatic tissues showed varying degrees of damage, the serum levels of AMS and LPS, and the pancreatic contents of IL-6, IL-1β, TNF-α and MDA were significantly increased, while the SOD activity was significantly decreased (all P<0.05), and further, the changing amplitudes of all above variables were successively decreased in the order of  model group, intraperitoneal injection group, tail vein injection group and combined injection group, and all differences had a statistical significance (all P<0.05). 
Conclusion: Bone MSC transplantation can inhibit inflammatory response, reduce oxidative stress and repair pancreatic tissue injury in SAP rats. The mechanism may be probably related to the regulation of TLR4/NF-κBp65 pathway.
Application value of enhanced recovery after surgery in perioperative management of pancreaticoduodenectomy
CAO Xintong, NING Caihong, LI Jiarong, LIN Jiayan, YANG Jianyi, ZHU Shuai, HUANG Gengwen
Chinese Journal of General Surgery. 2021, 30(3):  305-312.  doi:10.7659/j.issn.1005-6947.2021.03.008
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Background and Aims: Over the past years, the concept of enhanced recovery after surgery (ERAS) has applied in a variety of surgical fields, and achieved remarkable results. However, the application of ERAS in the perioperative period of pancreaticoduodenectomy (PD) is still limited. Therefore, this study was conducted to explore the application value of ERAS in perioperative management of PD through a prospective clinical analysis. 
Methods: A prospective series of 101 consecutive patients undergoing PD in the Department of Pancreatic Surgery, Xiangya Hospital, Central South University from December 2017 to September 2019 were enrolled. Of these patients, 32 cases adopted ERAS clinical pathway for perioperative management (ERAS group) and 69 cases received conventional protocols for perioperative management (conventional group). The clinical results were compared between the two groups of patients. 
Results: Compared to conventional group, the intraoperative blood loss of patients in ERAS group was significantly reduced (P<0.05). Moreover, the postoperative albumin level in ERAS group was significantly higher than that in conventional group, the time to the first postoperative anal gas passage and ambulation as well as the length of postoperative hospital stay were significantly shorter in ERAS group than those in conventional group, and the hospitalization cost in ERAS group was significantly lower in ERAS group than that in conventional group (all P<0.05). In terms of postoperative complications, the overall incidence of postoperative complication, the incidence rates of postoperative pancreatic fistula and pulmonary complications as well as proportion of cases with severe complications were significantly decreased in ERAS group compared with conventional group (all P<0.05).
Conclusion: The clinical application of ERAS protocols for perioperative management of PD is safe and feasible, which can effectively reduce the incidence of postoperative complications and accelerate the recovery of patients.
CT-based anatomical features of dorsal pancreatic artery and inferior pancreaticoduodenal artery in Chinese
YANG Ying, LIU Jian, WANG Xu, XU Tongjiang, LIU Jianxin, YIN Xiaoming
Chinese Journal of General Surgery. 2021, 30(3):  313-320.  doi:10.7659/j.issn.1005-6947.2021.03.009
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Background and Aims: Pancreatectomy is a complex procedure with a high risk of accidental intraoperative bleeding. Accurate preoperative assessment of the origin and running course of the peripancreatic vessels is helpful to reduce the risk of intraoperative bleeding. There is still lacking systematic study of the anatomy of peripancreatic vessels in Chinese population. The purpose of this study is to ascertain the anatomical characteristics of the dorsal pancreatic artery (DPA) and the inferior pancreaticoduodenal artery (IPDA) in Chinese, and further to explore the best post-processing method of CT images.  
Methods: The imaging data of patients who underwent abdominal enhanced CT examination from December 2016 to June 2017 were collected for multiplanar reconstruction (MPR), maximum intensity projection (MIP),  volume rendering (VR) and so on. The data of the DPA and IPDA were observed by two experienced radiologists who are familiar with the anatomy of pancreatic vessels, and the observed variables included the number of branches of the DPA and IPDA, the location of the origin, and the distance from the root of superior vessels. The detection rates of different CT post-processing techniques for corresponding vessels were also compared. 
Results: During the period, a total of 762 patients underwent abdominal enhanced CT examination. According to the inclusion and exclusion criteria, 211 patients were enrolled, including 98 males and 113 females, with age from 16 to 92 years, and BMI from 17.5 to 35.2 kg/m2. In the whole group of patients, the detection rates of the DPA and IPDA were 95.3% and 96.2%, respectively. The DPA arising from the celiac trunk (CA) accounted for 58.7%. Among them, 49.1% (58/118) originated from the splenic artery, and the average distance from the origin to the root was 4.6 (2–10) mm; 39.8% (47/118) were derived from the hepatic artery, and the average distance from the origin to the root was 6.4 (2–10) mm; in addition, 6.8% (8/118) and 4.2% (5/118) of the DPA came from the bifurcation of the CA and CA itself, respectively. The DPA arising from the superior mesenteric artery (SMA) accounted for 41.3%, and their origin sites were mostly located at the 9–12 points of the SMA (94.0%, 78/83), and the average distance from the root of SMA was 26 (18–45) mm. There were 171 cases (84.2%), 29 cases (14.3%) and 3 cases (1.5%) had one, two or three IPDA, respectively. According to the relationship between IPDA and the first jejunal artery (FJA), they were classified as common trunk or separate independent origins with the FJA. About 60.1% (122/203) of IPDA and the FJA originated from the same trunk. The root of IPDA usually located at 4–7 points of the SMA (75.4%, 92/122). The average distance from the root of SMA was 42 (18–54) mm. About 39.9% of the IPDA originated from the SMA directly, which was usually located at 6–9 points of the SMA, with an average distance of 40 (18–52) mm from the root of the SMA. A total of 10.4% of the IPDA (22/211) had the common trunk with the DPA. The display rates of 1-mm reconstruction, MIP and VR for DPA were 93.8% (198/211), 95.3% (201/211) and 94.3% (199/211) respectively, which were significantly better than those of 3 mm (81.5%, 172 / 211) or 5 mm (68.7%, 145/211) reconstruction (all P<0.01), and for IPDA were 94.8% (200/211), 96.2% (203/211) and 94.8% (200/211) respectively, which were also significantly better than those of 3 mm (78.2%, 165/211) or 5 mm (67.3%, 142 / 211) reconstruction (all P<0.01).
Conclusion: The origins and running courses of the DPA and IPDA are complex. Preoperative 1 mm CT reconstruction can clarify the anatomical characteristics of the DPA and IPDA, which is helpful for the dissection of related vessels and reducing the risk of accidental injury. 
Protective effect of early abdominal paracentesis drainage against kidney injury secondary to severe acute pancreatitis
YANG Xiong, LIU Ruohong, XIE Chuan, DONG Hongfei, WU Jun, SUN Hongyu, TANG Lijun
Chinese Journal of General Surgery. 2021, 30(3):  321-329.  doi:10.7659/j.issn.1005-6947.2021.03.010
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Background and Aims: Acute kidney injury (AKI) is a common early complication in patients with severe acute pancreatitis (SAP), and it is also an important cause for early death in patients with SAP. Effective prevention and treatment of early AKI in SAP patients are critical for the prognosis of patients. The abdominal cavity of patients with SAP at the early stage often accumulates pancreatitis-related ascitic fluid (PAAF), which can not only form intra-abdominal hypertension and cause kidney ischemic injury, but also can cause kidney injury through the reabsorption of a large number of inflammatory mediators, enzymes and other toxic substances into the blood. Therefore, removing PAAF may have a protective effect against SAP-related AKI. Abdominal paracentesis drainage (APD) can drain PAAF timely and effectively without increasing the risk of abdominal infection. However, whether APD can improve SAP-related AKI is unclear. To this end, this study was conducted to investigate whether early APD has a protective effect on SAP-related AKI, and try to provide clinical evidence for the early prevention and treatment of SAP-related AKI. 
Methods: The clinical data of 186 SAP patients who met the inclusion criteria admitted to the Western Theater General Hospital from January 2011 to January 2020 were retrospectively analyzed. According to whether acute kidney injury (AKI) had occurred at the time of admission, they were divided into AKI group (57 cases) and non-AKI group (129 cases). In AKI, 30 patients underwent APD and 27 patients did not receive APD; in non-AKI group, 65 patients underwent APD and 64 patients did not receive APD. The differences in treatment efficacy between patients with and without APD were compared in either group, respectively. The studied variables included acute kidney injury stage (AKIN stage), renal function indexes, inflammation indexes, and APACHE II score. 
Results: In AKI group, the downgrading rates of the AKIN stage in patients with and without APD were 80% (24/30) and 51.9% (14/27), respectively (χ2=5.067, P=0.024), while the upgrading rates were 0.0% (0/30), 18.5% (5/27), respectively (P=0.019); after 7 days of treatment, the renal function indexes, inflammation indexes, and APACHE II scores of the patients were significantly reduced, but the decreasing amplitudes of all indexes in patients undergoing APD were significantly greater than those in patients without APD treatment (all P<0.05). In non-AKI group, the upgrading rates of the AKIN stage (the incidence of AKI) in patients with and without APD were 4.6% (3/65) and 17.2% (11/64) (χ2=5.268, P=0.022); after 7 days of treatment, the renal function indexes, inflammation indexes, and APACHE II scores of the patients were significantly reduced, but the decreasing amplitudes of all indexes in patients undergoing APD were significantly greater than those in patients without APD treatment (all P<0.05). 
Conclusion: For SAP patients with a large amount of PAAF, regardless of whether they are combined with AKI at the time of admission, early APD treatment can not only effectively reduce the stage of renal injury in patients with AKI, reduce the incidence of renal injury in patients without AKI, but also effectively decrease renal function index and improve the systemic inflammation. So, it has preventive and therapeutic effects against kidney injury, with a demonstrable efficacy.
Research progress in immunotherapy for pancreatic ductal adenocarcinoma
WANG Puxiongzhi, YU Xinzhe, SHI Xiangjun, YUAN Zhou
Chinese Journal of General Surgery. 2021, 30(3):  330-336.  doi:10.7659/j.issn.1005-6947.2021.03.011
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Pancreatic ductal adenocarcinoma (PDAC) is a common malignant tumor of the digestive system, and characterized by a high degree of malignancy, high metastasis rate and low surgical resection rate. In recent years, significant progress has been made in tumor immunotherapy due to the application of immune checkpoint inhibitors that are represented by antibodies against programmed cell death protein 1/programmed death ligand 1 (PD-1/PD-L1). However, owing to the unique tumor microenvironment and low immunogenicity of PDAC, the immunotherapy of PDAC is still unsatisfactory. Here, the authors, combined with the microenvironmental characteristics of PDAC, address the latest research advances in terms of immune checkpoint inhibitors, adoptive cellular immunity, and tumor vaccines in the treatment of PDAC, as well as their application prospects.
Advances in clinical application of circulating tumor DNA in pancreatic cancer
LI Weiwei, LIU Jinlong
Chinese Journal of General Surgery. 2021, 30(3):  337-342.  doi:10.7659/j.issn.1005-6947.2021.03.012
Abstract ( 28 )   PDF (1072KB) ( 19 )   Save
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Pancreatic cancer is one of the most lethal malignancies in the world, and has an extremely poor prognosis. Because of the non-specific symptoms with insidious onset and rapid development, most patients are diagnosed at an advanced stage, which deprives them of adequate treatment opportunities. At present, most patients with pancreatic cancer are diagnosed by imaging examination, biochemical examination and tissue biopsy. Each of the existing methods has its own imperfections. In recent years, with the deepening research on tumor mechanism and the development of liquid biopsy technology, circulating tumor DNA (ctDNA) has gradually attracted extensive attention and played an increasingly important role. In this review, the authors describe the clinical application of ctDNA in pancreatic cancer in terms of early diagnosis, prognosis evaluation, chemotherapy efficacy, and targeted therapy.
Research progress of the role of neutrophil extracellular traps in pancreatic diseases
XIE Xuewen, FEI Shuke
Chinese Journal of General Surgery. 2021, 30(3):  343-348.  doi:10.7659/j.issn.1005-6947.2021.03.013
Abstract ( 20 )   PDF (1061KB) ( 19 )   Save
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A novel immune mechanism for neutrophil killing of pathogens, termed neutrophil extracellular traps (NETs), has become a hot topic of research in recent years. An increasing number of studies have shown that formation of NETs is involved in the pathophysiological processes of cardiovascular diseases, gallstone formation, inflammation, tumors and other diseases. Studies demonstrated that the presence of NETs is one of the pathogenesis of acute biliary pancreatitis (ABP) and an important factor in the progression of acute pancreatitis (AP), and furthermore, it is also a key factor in promoting the proliferation and metastasis of pancreatic cancer cells, as well as participating in the venous thrombus formation of pancreatic cancer patients. Here, the authors address the related topics.
The role of long non-coding RNAs in hepatocellular carcinoma
ZHOU Yan, CHEN Chao, YANG Zhulin, XIONG Li
Chinese Journal of General Surgery. 2021, 30(3):  349-356.  doi:10.7659/j.issn.1005-6947.2021.03.014
Abstract ( 22 )   PDF (1124KB) ( 12 )   Save
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Hepatocellular carcinoma (HCC) is a common malignant tumor of digestive system, and the third leading cause of cancer-related death with no effective treatment available at present. Long non-coding RNAs (lncRNAs) are RNA molecules with a transcript length of more than 200 nt and lack a protein-coding ability. Currently, lncRNAs are considered to play important roles in proliferation, apoptosis, metastasis, drug resistance and cancer stem cells regulation of HCC. Combined with the latest research progress in this field, the authors address the concept, characteristics and action mode of lncRNAs and their actions in the occurrence and development of HCC, and the exploration of lncRNA-based treatment of HCC. As an important regulator of HCC, lncRNAs are promising biomarkers and targets for the diagnosis and treatment of HCC.
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