Abstract:

Objective: To investigate the clinical value of penetrating-suture pancreaticojejunostomy. Methods: The clinical data of 83 patients undergoing pancreaticoduodenectomy (PD) from May 2006 to July 2014 were retrospectively analyzed. All patients received penetrating-suture pancreaticojejunostomy for pancreatic-enteric anastomosis during surgery, which was characterized by anastomosis of the cutting surface (not the cutting margin) of the pancreas to the jejunal wall, and anastomosis of the pancreatic duct to the intestinal mucosa. Results: Of 83 patients, 32 cases were carcinoma of the pancreatic head, 42 cases were periampullary carcinoma and 9 cases had other conditions; 81 cases underwent radical pancreaticoduodenal resection and two cases had non-radical resection. The operative time was 220 to 350 min, with an average of 290 min, and the time for pancreatic-enteric anastomosis was 6 to 22 min, with an average of 8 min. According to ISGPF criteria, clinically significant postoperative pancreatic fistula occurred in 8 cases, and all were grade B simple pancreatic fistulas. Bile leakage occurred in 2 cases and delayed gastric emptying occurred in 6 cases. No reoperation was needed and no anastomotic bleeding or surgical death occurred. Conclusion: The technique of penetrating-suture pancreaticojejunostomy can effectively prevent postoperative anastomotic failure at the pancreatic-enteric anastomosis and anastomotic bleeding.

Abstract:Objective: To assess the application value of pancreaticojejunostomy (PJ) with duct-to-mucosa running-through suture in pancreatieoduodenectomy (PD). Methods: The clinical data of 61 patients undergoing PD from January 2013 to March 2015 were retrospectively analyzed. Of the patients, 34 cases underwent PJ using the duct-to-mucosa through-and-through suture (observational group) and 27 cases underwent the conventional invagination PJ (conventional group). The clinical variables between the two groups were compared. Results: The general data were comparable between the two groups of patients. In observational group compared with conventional group, the time of intraoperative PJ was decreased [(14.9±1.6) min vs. (22.6± 2.6) min, P<0.05], the incidence of postoperative pancreatic fistula was reduced (11.76% vs. 37.03%, P<0.05), and the length of postoperative hospital stay was shortened [(16.5±4.9) d vs. (19.5±5.4) d, P<0.05]. There was no significant difference in intraoperative blood loss, incidence of other complications and postoperative 1-year survival between the two groups (all P>0.05). Conclusion: PJ with duct-to-mucosa running-through suture can reduce the incidence of postoperative pancreatic fistula, and it is a relatively simple and effective PJ method, and is recommended to be used in clinical practice.

Abstract:

Objective: To determine the clinical application value of laparoscopic pancreaticoduodenectomy (PD) with an uncinate process approach. Methods: The clinical data of 12 patients undergoing laparoscopic PD with uncinate process approach since February 2010 were reviewed. The essential feature of the operation was dissection of the uncinate process and the mesentery upwards along the right side of the superior mesenteric artery from the horizontal part of the duodenum, and then proceeding to conduct the other surgical procedures in the conventional order. Results: Of the 12 patients, 2 cases were converted to open surgery, and remaining 10 cases had successful laparoscopic PD. The operative time for laparoscopic PD was 240 to 340 min with an average of 280 min, the intraoperative blood loss was 150 to 1 200 mL with an average of 300 mL, and the number of dissected lymph nodes was 9 to 15 with an average number of 10. Postoperative pathological examination showed negative surgical margins. Postoperative pancreatic leakage and bile leakage occurred in 2 patients and 1 patient respectively, which were all cured after treatment. Conclusion: Laparoscopic PD with uncinate process-first approach is a safe, feasible and effective surgical procedure.

Abstract:

Objective: To assess the efficacy of pancreaticoduodenectomy (PD) followed by tegafur/gimeracil/oteracil (S-1) adjuvant chemotherapy in treatment of pancreatic cancer. Methods: Between February 2008 and June 2011, 58 patients with stage I-II pancreatic cancer underwent PD followed by postoperative adjuvant chemotherapy with S-1 (32 cases, observational group) or gemcitabine (26 cases, control group). The short- and long- term efficacies as well as the incidence of adverse events during chemotherapy between the two groups of patients were compared. Results: The levels of serum tumor markers in both groups of patients were significantly decreased after chemotherapy compared with their levels before chemotherapy (all P<0.05), but showed no significant difference between the two groups (all P>0.05); the overall response rate in observational group was significantly higher than that in control group (37.50% vs. 30.77%, P<0.05); survival analysis showed that the 1-, 1.5- and 2-year overall survival rate in observational group were significantly higher than those in control group (all P<0.05); the adverse reactions in either group were grade I or II, and there was no significant difference in incidence of adverse reactions between the two groups (P>0.05). Conclusion: PD plus postoperative S-1 adjuvant chemotherapy for pancreatic cancer patients has proven efficacy, which may effectively prolong the postoperative survival time of the patients, with only mild adverse effects, and good tolerance.

Abstract:Objective: To determine the relevant risk factors for the pathogenesis of periampullary carcinoma, so as to provide a theoretical reference for effective prevention and control of this conditioin. Methods: Using a 1:1 case-control matched design, 122 patients with periampullary carcinoma (case group) admitted during 2003 to 2014 and 122 patients without tumor or digestive disease admitted during the same period in Hunan Provincial People’s Hospital were enrolled. The possible risk factors were analyzed by conditional Logistic regression model. Results: Smoking, alcohol consumption and hepatitis B virus (HBV) infection were found to be the risk factors for periampullary carcinoma after controlling for confounding factors. The results showed that the risk of periampullary carcinoma increased in proportion with the increase in the number of cigarettes smoked per day, and odds ratio (OR) was 0.450 (95% CI=0.205–0.988), 0.500 (95% CI=0.092–2.730), 2.571 (95% CI=1.074–6.156) and 3.000 (95% CI=0.312–28.841) for those who did not currently smoke, smoked <20 cigarettes/d, 20–39 cigarettes/d and >40 cigarettes/d, respectively; the OR was 3.000 (95% CI=0.312–28.841), 65.289 (95% CI=0.006–70.239) and 4.500 (95% CI=0.972–20.827) for those who with alcohol consumption less than 40 g/d, 40-99 g/d and >100 g/d, respectively; the risk of periampullary carcinoma in cases with HBV infection was 3.25-fold higher than in those without history of HBV infection (95% CI=1.060–9.967). Conclusion: Heavy smoking, alcohol consumption and HBV infection are associated with increased risk of periampullary carcinoma.

Abstract:Objective: To investigate the influence of spleen preservation on prognosis of patients with pancreatic neuroendocrine neoplasms (PNEN) following distal pancreatectomy. Methods: The clinical data of 32 patients with PNEN undergoing surgical resection of the body and tail of the pancreas between February 2007 and July 2012 were analyzed retrospectively. Of the patients, 21 cases had combined splenectomy, and 11 cases had their spleen preserved. The postoperative survival of the two groups of patients was compared, and the prognostic factors for these patients were analyzed. Results: The postoperative follow-up ranged from 13 to 62 months, with an average of (41.86±5.14) months. The 1-, 3- and 5-year overall survival rate was 100%, 90.91%, and 81.82% in patients with spleen preservation, and was 90.48%, 80.95% and 76.19% in those having splenectomy respectively, and the postoperative survival in patients with spleen reservation was significantly superior than that in patients undergoing splenectomy (P<0.05). Univariate analysis showed that TNM stage, lymph node metastasis and nerve or vascular invasion, and splenectomy were related factors affecting the prognosis of the patients (all P<0.05), while multivariate analysis showed that only tumor TNM stage was the independent prognostic factor for the patients (P<0.05). Conclusion: Distal pancreatectomy with spleen preservation is beneficial for postoperative survival of patients with PNEN, but it does not independently affect the postoperative outcomes.

Abstract:Objective: To investigate the cliniopathologic features, diagnosis and treatment of pancreatic neuroendocrine neoplasms (PNEN), so as to provide knowledge for further understanding of this condition. Methods: The clinical and pathological data of the 9 PNEN patients admitted in the First Affiliated Hospital of Anhui Medical University from December 2011 to December 2013 were retrospectively analyzed. Results: Of the 9 patients, 3 cases were male and 6 were female; all cases underwent ultrasound and CT examination, and 2 cases had MRI examination. The imaging examinations showed that the tumor was located in the head of the pancreas in 3 cases, neck of the pancreas in one case, the tail of the pancreas in one case, the body and tail of the pancreas in 3 cases, and body and tail of the pancreas with concomitant tumor in the diaphragmatic surface of the liver in one case. The 9 patients exhibited dissimilar clinical symptoms, of whom one case with islet cell tumor had typical symptoms of hypoglycemia such as dizziness and fatigue accompanied with drowsiness, hunger sensation and unconsciousness, and the other cases had no typical symptoms. All patients received surgical treatment, and their diagnoses were confirmed by postoperative pathological and immunohistochemical examinations. Conclusion: PNEN has low prevalence, insidious onset and usually without specific clinical signs and symptoms. Its diagnosis mainly relies on pathological biopsy and immunohistochemical staining, and surgery is the first option of treatment.

Abstract:Objective: To investigate the diagnosis and treatment of insulinoma (pancreatic β-cell tumor). Methods: We admitted and treated one case of insulinoma, and that case together with the data of 1 362 patients with insulinoma documented in the literature in China were analyzed. Results: Of the 1 363 patients, 1 286 cases (94.35%) showed signs of Whipple’s triad, and the insulin to glucose ratio (IRI/G) was calculated in 1 099 patients, which in 1 019 cases (92.72%) was higher than 0.3. The preoperative tumor detection by B-type ultrasound scan, CT, MRI, selective angiography (DSA), selective arterial calcium stimulation (ASVS), Endoscopic ultrasonography (EUS), percutaneous transhepatic portal catheterization (PTPC), somatostatin receptor scintigraphy (SRS) and intraoperative ultrasound (IOUS) plus palpation was 40.90% (418/1 022), 55.20% (457/823), 52.45% (96/183), 77.42% (247/319), 89.47% (34/38), 78.68% (48/61), 86.11% (62/70), 36.36% (8/22), and 93.97% (312/332), respectively. All patients underwent surgery, and 1 006 cases (73.80%) received tumor enucleation. All of them were diagnosed as insulinoma by postoperative pathology, 42 cases (3.08%) had malignant change, 98 cases (7.19%) had multiple lesions, 28.25% tumors were located in the head of the pancreas, 33.90% in the body of the pancreas, and 37.83% in the tail of the pancreas. Pancreatic fistula occurred in 276 patients (20.25%). Recurrence occurred in 16 benign cases and in 7 malignant cases after operation. Conclusion: Whipple’s triad and IRI/G higher than 0.3 can be used as the main evidence for diagnosis of insulinoma. Preoperative localization can be made by combination of different methods, and IOUS plus palpation is a simple and effective method for intraoperative localization. Enucleation is the major surgical treatment for insulinoma.

Abstract:Objective: To investigate the influence of AFAP-1L2 down-regulation on pancreatic cancer cells and its mechanism. Methods: Human pancreatic cancer SW1990 cells were transfected with AFAP-1L2 targeting plasmids siAFAP-1L2 or negative control siRNA sequences, using untreated SW1990 cells as blank control, and then the migration and invasion ability, and the protein and mRNA levels of the molecules related to metastasis and invasion in each group of cells were detected. The interaction between AFAP-1L2 and p85α protein was tested by co-immunoprecipitation assay. Results: Compared with the blank control SW1990 cells, in SW1990 cells with down-regulated AFAP-1L2 expression after siAFAP-1L2 transfection, the migration and invasion ability was decreased, expressions of p85α and α-pAkt were decreased, and α-Akt expression was increased (all P<0.05), while the expressions of MMP-9 and E-cadherin showed no significant change (both P>0.05); all the studied parameters in SW1990 cells transfected with negative control siRNA seqeunces had no obvious change (all P>0.05). Co-immunoprecipitation assay showed that there was interaction between AFAP-1L2 and p85α protein in SW1990 cells. Conclusion: AFAP-1L2 may regulate PI3K/Akt pathway through interaction with p85α and thereby influence the migration and invasion of pancreatic cancer cells, and down-regulating AFAP-1L2 expression can decrease the migration and invasion ability of pancreatic cancer cells.

Abstract:Objective: To investigate the effect of dihydromyricetin (DHM) on adhesion, invasion and migration abilities of hepatocellular carcinoma (HCC) cells and the possible mechanisms. Methods: HCC MHCC97L cells were exposed to different concentrations of DHM, and then, the adhesion, invasion and migration abilities of the cells were examined, and the protein expressions of E-cadherin, MMP-2, MMP-9 and VEGF were also determined. Results: In MHCC97L cells treated with DHM compared with blank control cells, the abilities of adhesion, invasion and migration were all significantly deceased (all P<0.05), the E-cadherin expression was upregulated, and the MMP-9 and VEGF expressions were downregulated significantly, but the MMP-2 expression showed no significant change (P>0.05). Conclusion: DHM can inhibit the adhesion, invasion and migration of HCC cells by regulation of E-cadherin, MMP-9 and VEGF expressions.

Abstract:Objective: To investigate the relationship between the oxaliplatin (L-OHP)-resistance and epithelial-mesenchymal transition (EMT) in human gastric cancer cells. Methods: Human gastric cancer SGC-7901 cells were continuously exposed to L-OHP with a stepwise increase in concentration in vitro, to establish the L-OHP-resistant cell line SGC-7901/L-OHP, and then, morphological examination, population doubling time and drug sensitivity determination were performed to confirm the successful establishment of SGC-7901/L-OHP cells. The expression differences of the EMT-related markers N-cadherin and E-cadherin between SGC-7901/L-OHP cells and parental cells were compared. Results: The L-OHP -resistant cell line SGC7901/L-OHP was successfully established after 6-month induction, as evidenced by their shape transference from epithelial phenotype to mesenchymal cell phenotype, population doubling time was significantly longer than that of parental cells (P<0.05), and IC50 of L-OHP was 9.7 times that of parental cells. In SGC7901/L-OHP cells compared with parental SGC-7901 cells, the N-cadherin mRNA and protein expressions were significantly increased, while the E-cadherin mRNA and protein expressions were significantly decreased (all P<0.05). Conclusion: EMT is possibly an important mechanism for the development of L-OHP resistance in human gastric cancer cells.

Abstract:Objective: To investigate the postoperative complications of endoscopic retrograde cholangiopancreatography (ERCP) and the prevention and treatment strategies. Methods: The clinical data of patients undergoing ERCP in Xiangya Hospital of Central South University from December 2010 to May 2015 were retrospectively analyzed. Results: Among a total of 461 patients undergoing ERCP, successful operation was performed in 394 cases (85.5%), and the causes for operative failure were mainly due to duodenal papilla blockage and intestinal stricture resulting from tumors, ulcers or other factors, which prevented the passage of endoscope or guide wire. Of the 394 patients, complications occurred in 126 cases (27.3%), including post-ERCP pancreatitis (PEP) in 29 cases (6.3%), transitional hyperamylasemia in 47 cases (10.2%), biliary tract infection in 25 cases (5.4%), hemorrhage in 22 cases (4.7%), basket incarceration and breakage in one case (0.2%), and pancreatic duct stent obstruction in one case (0.2%); no perforation occurred in any of the cases; 4 cases (0.9%) died, mainly due to systemic infection initiated by acute cholangitis. The incidence of complications of diagnostic ERCP was lower than that of therapeutic ERCP (23.4% vs. 34.7%, P<0.05). Conclusion: PEP and biliary tract infections are common and significant complications after ERCP. Strict adherence to the indications of ERCP, improvement in surgical skill and appropriate administration of medication are effective methods for reducing the incidence of post-ERCP complications.

Abstract:Objective: To investigate the relationship between the intra-abdominal hypertension (IAH) and degree of severity of acute pancreatitis (AP). Methods: Eighty AP patients admitted from February 2014 to February 2015 were selected. Of the patients, 49 cases were mild AP (MAP group) and 31 cases were severe AP (SAP group) according to their APACHE II scores at admission. The intra-abdominal pressure (IAP) of the patients was monitored via indirect bladder pressure measurement, 4 h per session for 5 d, and those with IAP value higher than 12 mmHg in two consecutive measurements were diagnosed as IAH. The incidence of IAH between the two groups was compared, and the correlation between IAP value and APACHE II score was analyzed; the incidence of adverse clinical events between cases with and without occurrence of IAH among SAP patients was compared, and the predictive values of APACHE II score and IAP for adverse clinical events were assessed by ROC curve analysis. Results: The incidence of IAH in SAP group was significantly higher than that in MAP group (45.2% vs. 0%, P<0.05), and the results of Pearson correlation analysis showed that there was a positive correlation between IAP value and APACHE II (r=0.752, P<0.05); the incidence of each adverse clinical event in cases with IAH was significantly higher than that in cases without IAH among SAP patients (P<0.05), and the AUC of IAP value for predicting adverse clinical events was significantly greater than that of APACHE II score (0.892 vs. 0.610, P<0.05). Conclusion: IAH is closely related to the degree of severity of AP, and it also may affect the clinical outcome of AP patients. IAP has important clinical value in predicting the risk of adverse clinical events in SAP patients.

Abstract:Objective: To investigate the distribution and antimicrobial resistance of pathogens isolated from infections associated with acute necrotizing pancreatitis (ANP) and analyze their impacts on prognosis of the patients. Methods: The clinical data of 72 ANP patients complicated with infection admitted from October 2010 to October 2014 were retrospectively studied. Results: Of the 72 ANP patients, there were 47 cases (65.28%) with abdominal and retroperitoneal infection, 37 cases (51.39%) with respiratory infection, and 32 cases (44.44%) with bloodstream infection, and bloodstream infection was closely related to death of the patients (P<0.05). Of 235 pathogenic isolates, 159 (67.66%) were gram-negative bacteria, 60 (25.53%) were gram-positive bacteria and 16 (6.81%) were fungi, respectively. The top six common pathogens isolated were Acinetobacter baumanni (58 isolates, 24.68%), Pseudomonas aeruginosa (21 isolates, 8.94%), Klebsiella pneumonia (19 isolates, 8.09%), Enterococcus faecium/faecalis (19 isolates, 8.09%), Escherichia coli (18 isolates, 7.66%) and Staphylococcus aureus (11 isolates, 4.68%), respectively. Antimicrobial susceptibility testing indicated that the resistant rate for Acinetobacter baumanni and Pseudomonas aeruginosa to imipeniem was 95.92% and 52.63%, and to cefperazone-sulbactam was 59.26% and 50.00%, respectively. The detection rate of extended-spectrum β-lactamases (ESBLs) in Klebsiella pneumonia and Escherichia coli was 64.29% and 80.00%, respectively. The resistance rate of Klebsiella pneumonia and Escherichia coli to cefperazone-sulbactam was 31.58% and 18.75%, and to imipeniem was 23.08% and 7.14%, respectively. Of the 19 isolates of Enterococcus faecium/faecalis, there was only one isolate resistant to vancomycin, and no linezolid-resistant isolate was found. The detection rate of Methicilin-resistant Staphylococcus aureus was 72.73%, and no isolate resistant to vancomycin, linezolid or macrodantin was noted. None of the 16 isolates was found resistant to common antifungal drugs. Conclusion: Bloodstream infection is an important cause for death in ANP patients. The gram-negative bacteria are still the major pathogens causing infections in ANP patients, however, the proportion of gram-positive bacteria and fungi should not be neglected. Multi-drug resistant bacteria have become an increasing challenge to the treatment of ANP associated with infections.

Abstract:Objective: To observe the changes in distribution and density of the nerve fibers in remnant splenic tissue after subtotal splenectomy for splenomegaly due to portal hypertension, so as to evaluate the value of this procedure. Methods: Thirteen patients with splenomegaly due to portal hypertension undergoing subtotal splenectomy with retroperitoneal transplantation of pedicled remnant spleen were selected. The specimens of splenomegaly tissues after surgical resection and the remnant splenic tissues from puncture biopsy 8 years after surgery in these patients were obtained, and specimens of splenic tissues harvested from 13 cases with splenic trauma served as normal control. The distributions and densities of splenic nerve fibers with positive neuropeptide Y (NPY) and neurofilament 200 (NF200) were detected by immunohistochemical staining. Results: The distributions of either NPY or NF200 positive nerve fibers were similar among the three groups of splenic tissues, but the splenomegaly tissue showed a relatively high density of both positive nerve fibers. Quantitative analysis within the red pulp of the spleen showed that the densities of both NPY and NF200 positive nerve fibers in splenomegaly tissue were significantly higher than those in remnant splenic tissue or normal splenic tissue (all P<0.05), but there was no significant difference between splenic tissue and normal splenic tissue (both P>0.05). Conclusion: After subtotal splenectomy, the distribution and density of nerve fibers in the remnant spleen are approximately the same as those in normal spleen, which suggests that the nerve function in the remnant spleen may gradually return to normal after elimination of the high pressure environment.

Abstract:Objective: To investigate the effect of use of Focus ultrasonic scalpel on the protection of parathyroid gland (PT) during thyroid surgery. Methods: Ninety-six patients with thyroid cancer undergoing thyroidectomy from August 2011 to May 2015 were selected, and randomly designated to observational group and control group, with 48 cases in each group. Patients in observational group underwent surgery by using Focus ultrasonic scalpel while those in control group using traditional monopolar electrocautery. The relevant surgical variables, the parathyroid hormone (PTH) and Ca2+ levels before and after surgery as well as the incidence of postoperative PT injury between the two groups of patients were compared. Results: The surgical variables that included operative time, length of incision, intraoperative blood loss and postoperative drainage volume in observational group were all significantly superior to those in control group (all P<0.05). there was no significant difference in preoperative PTH and Ca2+ levels between the two groups (both P>0.05), but the postoperative PTH and Ca2+ levels were significantly higher in observational group than those in control group (both P<0.05). The incidence of postoperative PT injury in observational group was significantly lower than that in control group (4.2% vs. 16.7%, P<0.05). Conclusion: Application of Focus ultrasonic scalpel has proven effect on PT protection in thyroid surgery, and is helpful for preventing the occurrence of PT hypofunction.

Abstract:In recent years, laparoscopic pancreaticoduodenectomy (LPD) has gradually become the first considered surgical procedure by surgeons for cancers of the head of the pancreas and periampullary adenocarcinoma. Although scholars have different perspectives on whether LPD should be implemented, LPD is generally considered to be safe and feasible. The authors, based on literature review, address the current status and progress of LPD.

Abstract:Pancreatic cancer stem cells (PCSCs) play an important role in the occurrence and development of pancreatic cancer, and are also closely related to the mechanisms for chemotherapy resistance and metastasis of pancreatic cancer. Investigations of PCSCs with regard to their surface markers, isolation, identification, signal pathways, microenvironment, drug resistance, metastasis and targeted therapy may provide a new prospect for the clinical treatment of pancreatic cancer.