The beginnings and evolution of a pancreatic surgeon: a technical morphological analysis in first 5 years / 中华外科杂志

Objective: To explore the development of the pancreatic surgeon technique in a high-volume center. Methods: A total of 284 cases receiving pancreatic surgery by a single surgeon from June 2015 to December 2020 were retrospectively included in this study. The clinical characteristics and perioperative medical history were extracted from the medical record system of Zhongshan Hospital,Fudan University. Among these patients,there were 140 males and 144 females with an age (M (IQR)) of 61.0 (16.8) years(range: 15 to 85 years). The "back-to-back" pancreatic- jejunal anastomosis procedure was used to anastomose the end of the pancreas stump and the jejunal wall. Thirty days after discharge,the patients were followed by outpatient follow-up or telephone interviews. The difference between categorical variables was analyzed by the Chi-square test or the CMH chi-square test. The statistical differences for the quantitative data were analyzed using one-way analysis of variance or Kruskal-Wallis H test and further analyzed using the LSD test or the Nemenyi test,respectively. Results: Intraoperative blood loss in pancreaticoduodenectomy between 2015 and 2020 were 300,100(100),100(100),100(0),100(200) and 150 (200) ml,respectively. Intraoperative blood loss in distal pancreatectomy was 250 (375),100 (50),50 (65), 50 (80),50 (50),and 50 (100) ml,respectively. Intraoperative blood loss did not show statistical differences in the same operative procedure between each year. The operative time for pancreaticoduodenectomy was respectively 4.5,5.0(2.0),5.5(0.8),5.0(1.3),5.0(3.3) and 5.0(1.0) hours in each year from 2015 to 2020,no statistical differences were found between each group. The operating time of the distal pancreatectomy was 3.8 (0.9),3.0 (1.5),3.0 (1.8),2.0 (1.1),2.0 (1.5) and 3.0(2.0) hours in each year,the operating time was obviously shorter in 2018 compared to 2015 (P=0.026) and 2020 (P=0.041). The median hospital stay in 2020 for distal pancreatectomy was 3 days shorter than that in 2019. The overall incidence of postoperative pancreatic fistula gradually decreased,with a incident rate of 50.0%,36.8%,31.0%,25.9%,21.1% and 14.8% in each year. During this period,in a total of 3,6,4,2,0 and 20 cases received laparoscopic operations in each year. The incidence of clinically relevant pancreatic fistula (grade B and C) gradually decreased,the incident rates were 0,4.8%,7.1%,3.4%,4.3% and 1.4%,respectively. Two cases had postoperative abdominal bleeding and received unscheduled reoperation. The overall rate of unscheduled reoperation was 0.7%. A patient died within 30 days after the operation and the overall perioperative mortality was 0.4%. Conclusion: The surgical training of a high-volume center can ensure a high starting point in the initial stage and steady progress of pancreatic surgeons,to ensure the safety of pancreatic surgery.

Ten directions for improving clinical therapeutic effect of pancreatic cancer in the future / 中华外科杂志

Pancreatic cancer is one of the most malignant digestive system tumors. In the recent decade, the effect of diagnosis and treatment of pancreatic cancer has improved due to the renewal of treatment concept and the popularization of effective treatment. However, the overall efficacy of pancreatic cancer is still dismal and the 5-year survival rate is only about 10%. Further improving the diagnosis and treatment of pancreatic cancer is the top priority of oncology research and clinical practice. Based on past clinical and scientific research experience, the authors have proposed ten hot spots and future directions for a reference, which focusing on early prevention, early diagnosis, and early treatment of pancreatic cancer, molecular typing and precise treatment, new drug development and regimen combination, surgical technology and strategy change, model establishment and database development, as well as innovation of traditional Chinese medicine and breakthrough of treatment concept. A breakthrough in the diagnosis and treatment of pancreatic cancer in the next ten years is raising hope, when doctors can truly prevent and control pancreatic cancer.

Surgical management of concomitant pancreatic neuroendocrine tumors inhereditary tumor syndromes / 中国实用外科杂志

Pancreatic neuroendocrine neoplasms(pNENs)might present as part of complex hereditary(familial)syndromes caused by germline mutations such as multiple endocrine neoplasia type 1(MEN1),von Hippel-Lindau disease(VHL),tuberous sclerosis,and neurofibromatosis type1(NF1).Increasing knowledge of hereditary pNENs in both their genetic underpinnings and clinical implications has affected the entire spectrum of their surgical management.However,the appropriate surgical timing and management of concomitant pNENs inhereditary tumor syndromes is still debated.

The importance of multidisciplinary diagnosis and treatment of pancreatic neuroendocrine neoplasms / 中国实用外科杂志

Great progresses have been achieved in the diagnosis and treatment of pancreatic neuroendocrine tumors,especially in the close related field as radiology,medical oncology and surgery.It is difficult to accomplish high level of diagnosis and treatment of pancreatic neuroendocrine tumors if doctors only understand the progress of own specialty.The characters of pancreatic neuroendocrine tumors are complex clinical manifestation,long disease duration,and related to many clinical departments.The multidisciplinary pattern of diagnosis and treatment could significantly improve the survival and quality of life of patients while decreasing medical expense.Suergeons should emphasis the importance of multidisciplinary pattern of diagnosis and treatment in pancreatic neuroendocrine tumors.

Expression of dihydropyrimidine dehydrogenase negatively correlated with the prognosis of pancreatic ductal adenocarcinoma / 中华外科杂志

<p><b>OBJECTIVE</b>To detect the expression of dihydropyrimidine dehydrogenase (DPD) in pancreatic ductal adenocarcinoma (PDAC), and to investigate the relationships between DPD expression and the prognosis of PDAC.</p><p><b>METHODS</b>Immunohistochemistry and tissue microarray techniques were used to exam the expression of DPD in the cancerous tissue in 156 patients admitted from January 2005 to December 2009, including 89 males and 67 females, with the age ranging from 35 to 81 years. The median age was 55 years.</p><p><b>RESULTS</b>With the positive rate of DPD 55.1%, the expression of DPD was correlated with the differentiation (P = 0.001), TNM staging of tumor (P = 0.021). No relationship was observed between the vessel invasion (P = 0.265), lymphatic metastasis (P = 0.123), neural invasion (P = 0.598) and DPD expression. In the follow-up 117 patients the overall median survival time was 14.2 months, in 58 cases expressed negative, the median survival time was 20.6 months; 39 cases expressed "+" and "++", the median survival time was 12.3 months; 20 cases expressed "+++", the median survival time was 6.8 months. The expression of DPD in pancreatic cancer was correlated with the prognosis of patients, those with higher expression pattern exhibited shorter survival time (P < 0.05). Univariate survival analysis revealed that DPD expression, TNM staging, lymphatic metastasis and neural invasion were factors related to prognosis (P < 0.05), while differentiation levels and vessel invasion were not. Multivariate survival analysis revealed that DPD expression (P = 0.002), lymphatic metastasis (P = 0.000) were two independent prognostic factors.</p><p><b>CONCLUSIONS</b>The expression levels of DPD was correlated to differentiation levels of pancreatic cancer and TNM staging; those with higher expression of DPD showed shorter survival time. DPD expression, lymphatic metastasis were independent prognostic factors for pancreatic cancer.</p>

Application of serum protein profiling in diagnosis, prognosis and evaluation of curative effect of pancreatic adenocarcinoma / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To establish decision tree and logistic regression classification models for diagnosing pancreatic adenocarcinoma (PaCa) and for screening serum biomarkers related to evaluation of different stages and curative effects.</p><p><b>METHODS</b>Serum samples obtained from subjects with pancreatic adenocarcinoma (n = 58) and normal pancreas (n = 51) were applied to strong anion exchange chromatography (SAX2) chips for protein profiling by SELDI-TOF-MS to screen multiple serum biomarkers. Biomarker Wizard software and several statistical methods including algorithm of decision tree, logistic regression and ROC curves were used to construct the decision tree or logistic regression classification models.</p><p><b>RESULTS</b>Average of 61 mass peaks were detected at the molecular range of 2000-30,000, ten decision trees with the highest cross validation rate were chosen to construct the classification models, which can differentiate PaCa from normal pancreas with a sensitivity of 83.3% and a specificity of 100%. Logistic regression was used to achieve the AUC (0.976 +/- 0.011, P < 0.001) with a sensitivity of 77.6% - 91.4% and a specificity of 92.2% - 100%. Six mass peaks were combined by logistic regression to achieve the AUC 0.897 +/- 0.054, 0.978 +/- 0.021 and 0.792 +/- 0.107 (P < 0.05) in the three groups (patients at stage I and II, stage II and III, stage III and IV). One mass peak (M/Z 4,016) was screened (P < 0.05) significantly between the preoperative and postoperative PaCa samples and the intensity decreased weeks after operation.</p><p><b>CONCLUSION</b>Decision tree and logistic regression classification models of the mass peaks screened by SELDI-TOF-MS serum profiling can be used to differentiate pancreatic adenocarcinoma from normal pancreas, and is superior to CA 199. The detected mass peaks are helpful for the evaluation of curative effect and prognosis of pancreatic adenocarcinoma.</p>

Comparison of MRI manifestations and histopathologic findings in pancreatic head carcinoma in vivo ex vivo / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To prospectively analyze the correlation of MRI image characteristics with histopathological findings in pancreatic head carcinoma in vivo and ex vivo.</p><p><b>METHODS</b>Sixteen patients with pancreatic head carcinoma were examined by 1.5T MRI. MR sequences included pre-and post-contrast dynamic 2D FLASH T1WI, TSE T2WI + fat suppressed (FS). All fresh specimens were scanned again within an hour after resection during the Whipple procedure, and were then cut into slices along the direction of MRI scan. The MRI image characteristics were compared with gross and histopathologic findings of the specimens.</p><p><b>RESULTS</b>The tumor size ranged from 1.5 cm x 2.0 cm to 4.8 cm x 4.2 cm with a mean value of 3.6 cm x 3.1 cm. The MRI findings in vivo showed hypointensity in 14 lesions and isointensity in 2, and on 2D FLASH T1WI and TSE T2WI, all lesions displayed mixed intensity except 3 lesions with iso-intensity. During post-contrast dynamic pancreatic parenchymal phase, 15 lesions showed mild enhancement and 11 lesions had ring enhancement sign. Nine lesions displayed progressive irregular moderate enhancement during post-contrast dynamic hepatic phase. Four lesions showed enhancement with iso- and hyperintensity in post-contrast dynamic delayed phase. The MRI findings demonstrated that all lesions ex vivo had hypointensity on 2D FLASH T1 WI and mixed intensity on TSE T2WI + FS. Tumor tissues mainly displayed hypointensity, and the area containing tumor and inflammatory tissue showed iso-intensity on 2D FLASH T1WI. On T2WI + FS, the fibrosis proportion displayed hypo or isointensity, while the tumor and chronic inflammatory tissue demonstrated slight hyperintensity, and the zones of mucous degeneration or pancreatic ductal dilatation displayed hyper-intensity. The ring enhancement of tumor was caused by multiple factors and no obvious enhancement within tumor and fibrosis area were observed during post-contrast dynamic pancreatic parenchymal phase. Progressive irregular enhancement originated from desmoplastic reaction within the tumor during post-contrast dynamic hepatic phase and delayed phase, respectively.</p><p><b>CONCLUSION</b>Pancreatic head carcinomas contain various kinds of tissues. MRI can reveal these pathologic characteristics. No obvious hemorrhage and necrosis within the tumor were observed in this series.</p>

Clinical analysis of 18 cases with postsurgical gastroparesis syndrome after pancreaticoduodenectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the prevention and treatment for postsurgical gastroparesis syndrome (PGS) after pancreaticoduodenectomy.</p><p><b>METHODS</b>The data of 18 PGS cases after pancreaticoduodenectomy were analyzed.</p><p><b>RESULTS</b>PGS of these 18 patients occurred within 4-10 days after operation. All of the PGS patients were cured with mean 25.4 days by conservative therapy and no one received re-operation. PGS was closely associated with the operation procedure (chi(2)=3.90, P<0.05)and postoperative complications (chi(2)=3.92, P<0.05).</p><p><b>CONCLUSIONS</b>Incidence of PGS can be decreased by improvement of surgical procedure and prevention of abdominal complications. PGS can be cured by conservative therapy generally. Re-operation should be avoided.</p>

Clinical evaluation of 21 cases of total pancreatectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the clinical outcome of 21 cases of total pancreatectomy.</p><p><b>METHODS</b>The clinical data of 21 cases of total pancreatectomy performed from April 2003 to June 2006 was retrospectively analyzed.</p><p><b>RESULTS</b>Among the 21 patients, 1 case combined with transverse colon resection, 1 case with total gastrectomy, 9 cases with portal-superior mesentery vein resection with end-to-end anastomosis, 9 cases with portal-superior mesentery vein resection and grafts implantation, 8 cases with concomitant celiac axis resection, 4 cases with concomitant celiac axis and common hepatic artery resection, 1 case with concomitant celiac axis, portal vein and superior mesentery artery resection and reconstruction. Complications occurred in 12 cases (57.1%) post the operation and 5 cases (23.8%) died in 30 days after the operation. Insulin was given at the dose of 18 - 28 U daily post operation and blood glucose was maintained normal effectively. Sixteen cases were followed-up and median survival was 9.2 months (1.2 - 13.0 months). The median survival of tubular adenocarcinoma and intraductal papillary mucinous neoplasms of the pancreas (IPMNs) were 7 months (1.2 - 9.0 months) and 11.3 months (10.0 - 13.0 months), respectively.</p><p><b>CONCLUSIONS</b>Total pancreatectomy could not improve survival and it increases the complications and death, but it could improve the quality of life. It's an operation of choice for IPMNs, but with pancreatic carcinoma, the warranty of operation should be considered. The blood glucose level could be maintained normal effectively after the operation.</p>

Clinicopathologic analysis of 92 cases of pancreatic cystic neoplasm / 中华病理学杂志

<p><b>OBJECTIVE</b>To study the clinicopathologic and immunohistochemical features of cystic neoplasms of the pancreas.</p><p><b>METHODS</b>Ninety-two cases of cystic neoplasm of pancreas were retrieved from the Department archival file during the period from 1999 to 2005. Histologic features were studied and the tumors were typed according to WHO classification. Immunohistochemistry was also carried out using paraffin-embedded tissues.</p><p><b>RESULTS</b>The age of patients ranged from 16 to 80 years. The patients included 33 males and 59 females. The tumors varied from 2 cm to 21 cm in diameter. They consisted of intraductal papillary mucinous neoplasm (36/92), serous cystic neoplasm (18/92), solid pseudopapillary tumor (18/92), mucinous cystic neoplasm (14/92), cystic pancreatic ductal adenocarcinoma (4/92) and cystic pancreatic endocrine neoplasm (2/92). Immunohistochemical study revealed variable staining patterns, with frequent overlaps between different tumor types. In general, serous cystic neoplasm expressed MUC1, while mucinous cystic neoplasm was positive for MUC-5AC, intraductal papillary mucinous neoplasm for MUC-2 and cystic pancreatic ductal adenocarcinoma for MUC-1. On the other hand, solid pseudopapillary tumor expressed alpha-antitrypsin, alpha-antichymotrypsin, vimentin and progesterone receptor.</p><p><b>CONCLUSIONS</b>Accurate diagnosis of pancreatic cystic neoplasms requires correlation of clinical findings, radiologic examination, histologic features and immunostaining results. Pathologic distinction is important because of different prognostic significance. Two-thirds of pancreatic cystic neoplasms are premalignant or malignant and warrant surgical resection, whereas the remaining one-third (including pseudocyst and serous cystadenoma) are benign and can be treated conservatively.</p>

Evaluation of CT diagnostic criteria for peri-pancreatic artery and vein invasion in pancreatic carcinoma / 中华肿瘤杂志

<p><b>UNLABELLED</b>OBJECTIVE; To evaluate the clinical value of different CT diagnostic criteria for peripancreatic artery and vein invasion in pancreatic carcinoma through comparison with the findings on surgical exploration.</p><p><b>METHODS</b>Of 72 patients of having suspected pancreatic carcinoma were examined by multiplane spiral CT. Among 43 confirmed by surgical pathology; 15 underwent pancreaticoduodenectomy; 28 were found to have unresectable tumors. The peri-pancreatic major vessels including the superior mesenteric artery, celiac artery, hepatic artery, superior mesenteric vein and portal vein were explored carefully during surgical exploration.</p><p><b>RESULTS</b>The criteria for peri-pancreatic artery invasion was the presence of one of the following signs: artery embeded in tumor, or more than half of the artery circumference involved by tumor with wall irregularity or stenosis. The sensitivity of the above described criteria was 75.0% (12/16). If the criteria of tumor involvement exceeding half of the vessel circumference were adhered to, the sensitivity was 87.5% (14/16), which was high than the former, but the specificity was lower than that of the former one (90.2% versus 95.1%). The criteria for peri-pancreatic vein invasion was presence of any of the following signs: vein obliteration, more than half of the vein circumference involved by tumor, vein wall irregularity, vein stenosis, tear-drop sign of superior mesenteric artery. The sensitivity of the above described criteria was 92.9% (39/42), higher than that of the criteria that more than half of the vessel circumference was involved by the tumor (69.0%, 29/42), but the specificity of both criteria was the same (97.4%, 37/38).</p><p><b>CONCLUSION</b>For assessing peri-pancreatic artery and vein invasion, using the combination of different CT diagnostic criteria has higher accuracy than when using only criteria of more than half of vessel circumference involved by tumor.</p>

Evaluation of 2D and 3D MRI imaging in the diagnosis of pancreatic carcinoma / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To evaluate various kinds of sequences and modified dynamic contrast-enhanced MRI methods in the diagnosis of pancreatic carcinoma.</p><p><b>METHODS</b>Forty-nine pancreatic carcinoma patients proved by histopathology or clinical examination and follow-up underwent MR examination. Plain MR sequences included: T1-weighted 2D FLASH, T1 WI 3D VIBE, TSE T2 WI and HASTE with FS. Modified dynamic contrast-enhanced scanning procedures were coronal scaning with 3D FLASH and axial scaning using T1 WI 3D VIBE sequences in turn for the upper abdominal area and pancreatic area. The coronal imaging were used to obtain 3D peripancreatic vessels during arterial phase and portal vein phase scanning, respectively. The axial imaging were used to detect the tumor in pancreatic parenchymal phase and delayed phase scanning, respectively. Final scanning for the whole upper abdomen was performed using T1 WI 2D FLASH axial sequence.</p><p><b>RESULTS</b>(1) Of 49 lesions in these patients, 45 showed hypo-intensity and 4 iso-intensity on 3D VIBE. Forty-six lesions showed hypo-intensity and 3 isointensity on 2D FLASH. On TSE T2 + FS, lesion contour was not clear enough; 3 of them displayed isointensity, the other showed iso- or hyper-intensity. (2) During pancreatic parenchymal phase, 48 lesions showed hypo-intensity and 39 ring enhancement. Twenty-four lesions displayed marginal tubercle and inner compartment enhancement during portal vein and delayed phase. Six lesions showed iso- or hyper-intensity in delayed phase. (3) Thirty-seven patients underwent surgical exploration. MRI and MRA had a good correlation with surgical findings for peripancreatic vessels which were diagnosed as being invasive or noninvasive by tumors except three superior mesenteric arteries and four superior mesenteric veins being misdiagnosed.</p><p><b>CONCLUSION</b>As"one-stop-shop" MRI examination, modified MRI sequences consisting of dynamic coronal and axial contrast-enhanced scanning is feasible and helpful in diagnosing, staging and assessing the resectability for pancreatic carcinoma.</p>

MRI in the evaluation of peripancreatic vessel invasion and resectability of pancreatic carcinoma / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To investigate the role of MRI in evaluating the peripancreatic vessel invasion and resectability of pancreatic carcinoma based on the comparison of MRI image with surgical exploration, and try to establish the criteria for assessment of the sensitivity, specificity and accuracy of resectability.</p><p><b>METHODS</b>Forty-one pancreatic carcinoma patients confirmed by pathology received preoperative plain and contrast enhanced MRI scan, and 37 of them had additional coronal MRA scan. Peripancreatic vessel invasion was preoperatively assessed based on MRI features, and the vessel invasion degree from the uninvolved to the severely involved was divided into 6 grades represented by 1, 2a, 2b, 3a, 3b and 4, respectively. Compared with the findings during the surgery, the sensitivity and specificity of each vessel invasion grade were studied and the receiver operator characteristic curve (ROC) was drawn. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of resectability evaluation based on 2 and 2a degree were calculated respectively. The resectability of involved arteries and veins of grade 2 were also analyzed.</p><p><b>RESULTS</b>Of the 41 patients, 22 had resectable tumor, with 20 curative resection and 2 palliative. Compared with the findings during surgery, seven vessels including three arteries and four veins were not correctly interpreted by MRI. If grade 1,2a,2b,3a and 3b was used as the resectable standard,respectively, the sensitivity to predict the unresectbility was 78.3%, 84.8%, 67.4%, 56.5% and 47.8%, respectively. Receiver operator characteristic curve demonstrated that grade 2a was the optimal critical point. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of grade 2a in predicting the unresectbility were 84.8%, 98.5%, 92.9%, 96.6% and 95.9%.</p><p><b>CONCLUSION</b>Our data showed that grade 2a (tumor involvement < 2 cm long and < 1/2 circumference of the vessel) may be more sensitive and accurate in predicting the resectability, which may be considered as the line of demarcation between the respectable and unresectable cases in clinical practice.</p>

CT diagnosis of intraductal papillary mucinous tumor of the pancreas / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To investigate the CT and MRI manifestatitions of intraductal papillary mucinous neoplasm (IPMN) of the pancreas.</p><p><b>METHODS</b>Both clinical and imaging data of 12 pathologically confirmed intraductal papillary mucinous neoplasm, of the pancreas were retrospectively analyzed.</p><p><b>RESULTS</b>The pancreatic IPMN can be classified into two types based on CT image: the branch duct IPMN (n=7) originated from the head and uncinate process of the pancreas. The tumor consisted of lobulated or clustered small cyst lesions with septa among them, the wall and septa can be enhanced; the combined IPMN (n=5) involved branch ducts of the uncinate process as well as the main pancreatic ducts with dilatation (diameter: 4-7 mm), one of these involved the branch ducts along the pancreatic body. The pancreatic IPMN was mainly found in elderly patient with a chief clinical symptoms of abdominal pain and/or pancreatitis.</p><p><b>CONCLUSION</b>The intraductal papillary mucinous neoplasm of the pancreas enjoys specific features in CT and MRI image, which are helpful to the diagnosis.</p>