Diagnosis and surgical treatment of autoimmune pancreatitis / 中华普通外科杂志

Objective:To explore the indications and effect of surgical treatment of autoimmune pancreatitis.Methods:Clinical data of these 15 patients with autoimmune pancreatitis diagnosed and treated at the Department of General Surgery, the First Hospital of Peking University from 2010 to 2021 were retrospectively analyzed.Results:The main clinical symptoms were obstructive jaundice, abdominal pain, distension and weight loss. The diagnosis of AIP was confirmed by EUS-FNA in 6 patients,among them, 4 did not relapse after oral hormone treatment, 2 did not receive relevant treatment, and 1 developed gastric cancer one year later. Under a suspicion of malignancy, 9 patients underwent surgical laparotomy ,and the diagnosis was established by pathology. There was no recurrence after oral hormone therapy in 1 patient who underwent laparotomy and pancreatic biopsy. One out of the 3 patients with choledochojejunostomy relapsed after 3 years. Of the 5 patients who underwent pancreatectomy, 4 had no obvious recurrence, and 1 had recurrence after 3 years.Conclusions:Untypical autoimmune pancreatitis is likely to be misdiagnosed as pancreatic cancer. For patients with suspicious malignancy, operational management and biopsy may benefit.

Clinical imaging features and prognosis of von Hippel-Lindau syndrome associated with pancreatic lesions / 中华消化外科杂志

Objective:To investigate the clinical imaging features and prognosis of von Hippel-Lindau (VHL) syndrome associated with pancreatic lesions.Method:The retrospective case-control study was conducted. The clinicopathological data of 161 patients with VHL syndrome who were admitted to Peking University First Hospital from September 2010 to August 2022 were collected. There were 83 males and 78 females, with age of onset as 27.0(range, 8.0-66.0)years. Observation indicators: (1) imaging results of VHL syndrome associated with pancreatic lesions; (2) clinical characteristics of VHL syndrome associated with pancreatic lesions; (3) comparison of clinicopathological factors in patients with VHL syndrome associated with pancreatic cystic lesions; (4) comparison of clinicopathological factors in patients with VHL syndrome associated with pancreatic neuroendocrine neoplasms (pNENs). (5) Treatment and prognosis of patients with VHL syndrome associated with pancreatic lesions. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was conducted using the non-parameter test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test. Results:(1) Imaging results of VHL syndrome associated with pancreatic lesions. Of the 161 patients with VHL syndrome, there were 151 patients associated with pancreatic lesions and 10 patients not associated with pancreatic lesions. Of the 151 patients with VHL syndrome associated with pancreatic lesions, there were 136 patient with pancreatic cystic lesions and 34 patients with pNENs, 22 patients with both pNENs and pancreatic cystic lesions, and the type of pancreatic lesions could not be accurately determined in 3 cases. (2) Clinical characteristics of VHL syndrome associated with pancreatic lesions. The age of onset in 151 patients with VHL syndrome associated with pancreatic lesions was 33.0(range, 14.0-68.0)years. Cases with gene site mutation of exon 1, exon 2, exon 3 and other types of gene site was 51, 16, 43 and 41, respectively. There were 116 patients of VHL type 1 and 35 patients of VHL type 2. There were 92 patients with family history of VHL syndrome and 59 patients without family history of VHL syndrome. There were 127 patients combined with renal cell carcinoma, 112 patients combined with central nervous system lesions, 46 patients combined with retinal hemangioblastoma. Patients may combined with multiple lesions. (3) Comparison of clinicopathological factors in patients with VHL syndrome associated with pancreatic cystic lesions. The age of onset, VHL syndrome type (VHL1 type, VHL2 type) and cases combined with renal cell carcinoma were 32.5(range, 14.0-68.0)years, 110, 26 and 115 in 136 patients with VHL syndrome associated with pancreatic cystic lesions, versus 22.0(range, 8.0-64.0)years, 13, 12 and 14 in 25 patients with VHL syndrome not associated with pancreatic cystic lesions, showing significant differences in the above indicators between them ( Z=-3.384, χ2=9.770, 10.815, P<0.05). (4) Comparison of clinicopathological factors in patients with VHL syndrome associated with pNENs. The age of onset, gene mutation sites (exon 1, exon 2, exon 3, other types of gene site) and VHL syndrome type (VHL1 type, VHL2 type) were 33.5(range, 14.0-64.0)years, 12, 5, 14, 3 and 18, 16 in 34 patients with VHL syndrome associated with pNENs, versus 27.0(range, 9.0-66.0)years, 41, 12, 32, 42 and 105, 22 in 127 patients with VHL syndrome not associated with pNENs, showing significant differences in the above indicators between them ( Z=-4.030, χ2=8.814, 13.152, P<0.05). (5) Treatment and prognosis of patients with VHL syndrome associated with pancreatic lesions. Of the 161 patients with VHL syndrome, 3 patients underwent surgical treatment, and the remaining patients were followed up. All 161 patients with VHL syndrome were followed up for 6 (range, 1-12)years, in which 15 patients died and 146 patients alive during the follow-up. The follow-up time of 3 patients undergoing surgical treatment was 4, 14, 9 years, respectively, and all of them were alive. Conclusions:The clinical imaging features of pancreatic lesions related to VHL syndrome are cystic lesions and pNENs, which with the characteristics of multiple lesions and benign tumors. Such patients usually do not requiring surgical treatment and have good prognosis.

'Oasis' in 'death desert': attach importance to the diagnosis and treatment for pancreatic cancer with microsatellite instability-high/deficient mismatch repair / 中华消化外科杂志

Pancreatic cancer (PC) is a malignant digestive tract tumor with poor prognosis. Most of patients with PC are insensitive to traditional strategies of chemotherapy, targeted therapy and immunotherapy. PC with microsatellite instability-high/deficient mismatch repair (MSI-H/dMMR) is rare in clinic, which has distinctive clinicopathological characteristics and better prognosis from conventional PC. Reasonable acquisition of pancreatic tumor biopsy and accurate assessment of MSI-H/dMMR status are helpful for accurate diagnosis of such patients. Individualized treatment strategy based on immunotherapy can significantly improve the prognosis of patients with MSI-H/dMMR PC. Based on relevant literatures of domestic and foreign, the authors discuss the current status and research hotspots of diagnosis and treatment for MSI-H/dMMR PC.

Practice and progress of interventional ultrasound in the diagnosis and treatment of acute abdomen / 国际外科学杂志

Acute abdominal pain is one of the most frequent complaints of patients presenting to the emergency department. Timely diagnosis and correct treatment affect the prognosis of patients. Traditional diagnosis mostly depends on physical examination and radiology. In terms of treatment, some patients need exploratory laparotomy. In recent years, with the development of interventional ultrasound, new techniques such as contrast-enhanced ultrasound, ultrasound-guided biopsy, drainage have been gradually applied to the diagnosis and treatment of surgical acute abdomen, especially the surgeon-performed interventional ultrasound, which has effectively improved the diagnostic efficiency and broadened the treatment choice. In this article, we aim to review and evaluate the application and progress of interventional ultrasound in the diagnosis and treatment of surgical acute abdomen.

Risk factors analysis and treatment of postpancreaticoduodenectomy hemorrhage / 中华消化外科杂志

Objective:To investigate the risk factors and treatment of postpancreatico-duodenectomy hemorrhage(PPH).Methods:The retrospective case-control study was conducted. The clinical data of 712 patients who underwent pancreaticoduodenectomy in Peking University First Hospital from January 2012 to November 2021 were collected. There were 392 males and 320 females, aged from 16 to 89 years, with a median age of 62 years. Observation indicators: (1) diagnosis of PPH; (2) analysis of influencing factors for PPH; (3) treatment of PPH. Measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers or percentages. Univariate analysis was performed using the chi-square test or Fisher exact probability, and multivariate analysis was performed using the Logistic regression model. Results:(1) Diagnosis of PPH. Of the 712 patients, 72 cases had PPH and 7 cases died. The incidence of PPH was 10.11%(72/712), and PPH related mortality was 9.72%(7/72). There were 7 cases of early PPH and 65 cases of delayed PPH. There were 23 cases of mild PPH and 49 cases of severe PPH. (2) Analysis of influencing factors for PPH. Results of univariate analysis showed that preoperative serum total bilirubin (TBil), extended surgery, postoperative pancreatic fistula, postoperative biliary fistula, postoperative abdominal infection were related factors for delayed PPH ( χ2=13.17, 3.93, 87.89, 22.77, 36.13, P<0.05). Results of multivariate analysis showed that preoperative serum TBil ≥171 μmol/L, postoperative grade B or C pancreatic fistula, postoperative biliary fistula, postoperative abdominal infection were independent risk factors for delayed PPH ( odds ratio=1.91, 8.10, 2.11, 2.42, 95% confidence interval as 1.09-3.33, 4.62-14.20, 1.06-4.23,1.35-4.31, P<0.05). (3) Treatment of PPH. ① Treatment of early PPH. Of the 7 cases with early PPH, 4 cases had mild PPH and 3 cases had severe PPH. The 4 cases with mild PPH were stanched by conservative treatment. The bleeding location of the 3 cases with severe PPH were the posterior wall of pancreatoenteric anastomosis, the pancreatic uncinate stump and the unintentional puncture of the jejunostomy tube of the left upper abdominal wall vessels and the 3 cases were stanched by reoperation. All the 7 cases were discharged without other complications. ② Treatment of delayed PPH. Of the 65 cases with delayed PPH, 19 cases had mild PPH and 46 cases had severe PPH. Of the 19 cases with mild PPH, 18 cases were stanched by conservative treatment including 2 cases died of pancreatic fistula and abdominal infection, 1 case were stanched by endoscope therapy. Of the 46 cases with severe PPH, 18 cases with stable vital signs and slow bleeding were stanched by conservative treatment including 1 case died of infectious toxic shock and the other 28 cases underwent invasive treatment, including 2 cases undergoing gastroscopy, 20 cases undergoing interventional treatment and 6 cases under-going reoperation as the initial treatment. Of the 22 cases taking endoscope or interventional treatment as the initial treatment, 5 cases underwent rebleeding and 2 cases died, with the reblee-ding rate and mortality as 22.7%(5/22) and 9.1%(2/22), respectively. Of the 6 cases taking reopera-tion as the initial treatment, 3 cases underwent rebleeding and 2 cases died, with the rebleeding rate and mortality as 3/6 and 2/6, respectively. There was no significant difference in the rebleeding rate and mortality in patients taking endoscope or interventional treatment as the initial treatment and patients taking reoperation as the initial treatment ( P>0.05). Of the 28 cases undergoing invasive treatment, 10 cases underwent secondary surgical treatment, including 6 cases taking reoperation and 4 cases taking interventional treatment as the initial treatment for hemorrhage, and 4 cases died with the mortality as 4/10, and the other 18 cases who did not receive secondary surgical treatment survived. There was a significant difference in the mortality between patients with or without secondary surgical treatment ( P<0.05). Conclusions:Preoperative serum TBil ≥171 μmol/L, post-operative grade B or C pancreatic fistula, postoperative biliary fistula, postoperative abdominal infection are independent risk factors for delayed PPH. Surgical treatment should be performed decisively for early severe PPH. For delayed severe PPH patients who undergoing conservative treat-ment without effect, endoscope therapy and interventional treatment should be the first choice, and surgical treatment should be performed if those above procedures not working.

Management strategies of pancreatic carcinoma in the era of systemic therapy: surgery first or surgery last / 中华消化外科杂志

Although the resection rate and surgical safety of pancreatic cancer has been significantly increased in recent years, however, the long-term prognosis of the patient remains dismal. In the era of multidisciplinary diagnosis and treatment, "surgery first", the traditional management strategy of pancreatic carcinoma, has been questioned and challenged because pancreatic carcinoma should be regarded as a systemic disease. For patients with locally advanced, borderline resectable or resectable tumors with high risks of recurrence, the option of "surgery last" should be advocated, which promotes systemic therapy. For patients with resectable tumors with better biological behaviors, the option of "surgery first" should be recommended.

The expression of miR-324-5p in pancreatic cancer and its effects and mechanisms on proliferation and migration of pancreatic cancer cells / 中华肝胆外科杂志

Objective:To investigate the expression and clinical relevance of micro RNA (miR)-324-5p in pancreatic cancer tissues, and to explore the effects and potential mechanisms of miR-324-5p on the proliferation and migration of pancreatic cancer cells.Methods:Real-time quantitative PCR was used to detect the expression of miR-324-5p in 34 pairs of pancreatic cancer and adjacent normal tissues resected at Peking University First Hospital from October 2018 to September 2019. The correlations between miR-324-5p expression and clinicopathological characteristics and prognosis of pancreatic cancer were analyzed using data from the Cancer Genome Atlas (TCGA) database. Real-time PCR was used to detect the expression of miR-324-5p in pancreatic cancer cell lines, and PANC-1 cell was used for functional study by overexpressing miR-324-5p via mimic transfection. CCK8 assay was used to evaluate cell proliferation. Both transwell and scratch wound healing assay were used to assess the cancer cell migration ability. Related proteins were detected by Western blot. The potential downstream target genes of miR-324-5p were selected using data from miRNA target genes predicted webs, in combination with functional analysis and their expressional correlation with miR-324-5p.Results:Data from TCGA database showed that the expression of miR-324-5p in tumor tissues was significantly lower than that in normal pancreatic tissues. And low level of miR-324-5p in pancreatic cancer was correlated with poor prognosis. Analysis of 34 pairs pancreatic cancer and adjacent normal tissues showed that miR-324-5p expression in tumor tissues (11.7±2.0) was significantly lower than that in adjacent normal tissues (70.9±14.4), and the pancreatic cancer patients who had the nerve invasion cancer showed low level of miR-324-5p (82.1%, 23/28) was significantly higher than that patients with high level of miR-324-5p (33.3%, 2/6). The expression of miR-324-5p in human pancreatic cancer cell line was also significantly lower than that in normal pancreatic ductal cells. CCK-8 assay showed that the proliferation ability of PANC-1 cell was significantly decreased when miR-324-5p was overexpressed. Transwell and wound healing assays showed that the capabilities of vertical migration and the horizontal movement were significantly inhibited in PANC-1 cell with miR-324-5p overexpressed [(30.11±5.2) and (174.6±27.0) μm, respectively] than those in control groups [(63.6±4.2) and (458.3±22.3) μm, respectively]. Moreover, Western blots showed a significant overexpression of miR-324-5p inhibited epithelial-mesenchymal transition (EMT). According to the data from miRNA target genes prediction and the functional analysis we found KLF3, MGAT3, PBX1 and ZNRF2 were considered as the potential downstream target genes of miR-324-5p.Conclusions:Our results indicated that miR-324-5p is lowly expressed and acts as the tumor suppressor gene in pancreatic cancer, and low level of miR-324-5p is correlated to a higher rate of nerve invasion and poor prognosis. In human pancreatic cancer cell, miR-324-5p may regulate EMT by directly inhibiting target genes such as KLF3, MGAT3, PBX1, ZNRF2, which in turn suppresses cancer cell proliferation and migration.

Clinicopathological characteristics and treatment strategies of undifferentiated carcinoma with osteoclast-like giant cells of pancreas / 中华消化外科杂志

Objective:To investigate the clinicopathological characteristics and treatment strategies of undifferentiated carcinoma with osteoclast-like giant cells of pancreas (UCOGCP).Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 5 patients with UCOGCP who were admitted to Peking University First Hospital from January 2004 to January 2019 were collected. There were 1 male and 4 females, aged from 33 to 71 years, with a median age of 56 years. Patients underwent preoperative laboratory test, imaging and histopatho-logical examinations. Patients with pancreatic head tumors underwent pancreaticoduodenectomy, and those with tumors in the body or tail of pancreas underwent distal pancreatectomy combined with splenectomy. All patients underwent standard lymph node dissection. Postoperative adjuvant therapy was individually decided by a multidisciplinary team. Observation indicators: (1) preopera-tive examination and treatment; (2) postoperative histopathological situations; (3) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect tumor recurrence of patients up to January 2020. Measurement data with normal distribution were represented as Mean± SD. Measurement data with skewed distribution were described as M (range). Count data were described as absolute numbers. Results:(1) Preoperative examination and treatment: of the 5 UCOGCP patients, CA19-9 was elevated as 65.43 U/mL in only 1 patient preoperatively, while the CA19-9 was normal in other 4 patients. Four patients showed a solid cystic mass on preoperative contrast-enhanced computed tomography (CT) scan, and 1 patient showed a delayed peripheral enhancement of the solid tumor with central necrosis. The magnetic resonance imaging (MRI) scan showed hypointense signals on T1, T2 and weighted diffusion sequences in all 5 patients. Three of the 5 patients were resectable according to imaging data, 1 patient had locally advanced tumor, infiltrating the transverse colon, stomach, and partial small intestine, with the portal vein thrombus, and 1 patient had pancreatic head tumor with a liver metastatic lesion of 0.4 cm diameter which was detected on position emission tomography CT and was diagnosed as UCOGCP by endoscopic ultrasound-guided fine-needle aspiration biopsy. All patients underwent radical resection. Of the 3 patients with resectable tumors, 2 patients underwent pancreaticoduo-denectomy and 1 patient underwent distal pancreatectomy combined with splenectomy. One patient with locally advanced tumor in the body and tail of pancreas underwent distal pancreatectomy + transverse colostomy + partial gastrectomy + portal vein thrombectomy, and 1 patient with pancreatic head tumor and liver metastasis underwent pancreatoduodenectomy combined with left lateral hepatectomy. Of the 5 patients, 2 received postoperative adjuvant chemotherapy with single-agent gemcitabine, 1 received albumin-paclitaxel+gemcitabine combination chemotherapy, 1 received S1 as single agent chemotherapy, and 1 did not receive adjuvant chemotherapy. (2) Postoperative histopathological situations: of the 5 patients, 4 cases showed a cystic solid appearance of gross specimens, and 1 case had a solid appearance with central hemorrhagic necrosis. The tumor diameter was 5.2 cm(range, 2.0?14.0 cm). All the 5 patients achieved negative margins. Of the 5 patients, there was 1 case with portal vein invasion, 2 cases with vascular invasion, 3 cases with perineural invasion, and 2 cases with regional lymph node metastasis. One patient may had multiple tumor invasion and metastasis. Four of 5 patients had paraffin specimens available for immuno-histochemical staining. Four patients were positive for both CD68 and vimentin stains, while 3 patients were positive for programmed death ligand-1 (PD-L1), including 2 samples with 5% positive cells and 1 sample with 25% positive cells. Postoperative pathological examination showed a large number of spindle histiocytoid sarcoma cells scattered with osteoclast like giant cells and pleomorphic carcinoma giant cells. The tumor mutation burden in the 4 patients was 3.23 Muts/Mb(range, 2.61?21.77 Muts/Mb). Microsatellite status was stable in 4 patients. The next generation sequencing of 4 patients showed that all patients had KRAS mutation which was the most frequently mutation in pancreatic ductal adenocarcinoma. Of the 4 patients, 1 case had germline pathogenic mutation in TP53, 1case had somatic mutation in TP53, 1 case had somatic mutation in TP53, BLM, CDKN2A, and 1 case had somatic mutation in ARID1A. (3) Follow-up: 5 patients were followed up for 14?173 months, with a median follow-up time of 46 months. During the follow-up, 4 patients achieved disease-free survival and 1 patient had local recurrence at postoperative 11 months.Conclusions:UCOGCP is a rare variant of pancreatic tumor that exhibits a cystic solid mass in imaging examinations. High expression of PD-L1 is common in UCOGCP. The prognosis for UCOGCP is favorable following radical surgery. Patients may benefit from extended radical surgery even if the tumor has locally progression or distant metastasis.

Surgical resection or palliative care for pancreatic cancer with liver oligometastasis / 中华消化外科杂志

The prognosis of pancreatic cancer is the worst in all kinds of digestive tract tumors. Fifty percent of pancreatic cancer patients have distant metastasis at the time of diagnosis, and liver is the most common site of metastasis. For pancreatic cancer patients, the presence of distant metastasis has been always considered as an absolute contraindication for surgical resection. However, with the establishment of multidisciplinary team, especially the researches of chemotherapy and targeted drugs and the application of new chemotherapy regimens in recent years, there are more and more evidences which show the survival benefit of surgical resection for some selected patients with liver oligometastasis after systemic chemotherapy. In this paper, the authors review current situation and progress in the treatment strategy for pancreatic cancer with hepatic oligometastasis, further investigate the indication of surgical treatment and evaluate its clinical outcomes.

MicroRNAs as potential therapeutic targets for pancreatic cancer / 中华医学杂志(英文版)

Pancreatic cancer is one of the most aggressive malignancies. The poor prognosis of pancreatic cancer patients is mainly attributed to low diagnostic rate at the early stage, highly aggressive nature coupled with the inadequate efficacy of current chemotherapeutic regimens. Novel therapeutic strategies are urgently needed for pancreatic cancer. MicroRNAs (miRNAs) play an important regulatory role in key processes of cancer development. The aberrant expression of miRNAs is often involved in the initiation, progression, and metastasis of pancreatic cancer. The discovery of tumor suppressor miRNAs provides prospects for the development of a novel treatment strategy for pancreatic cancer. We reviewed recent progress on the understanding of the role of miRNAs in pancreatic cancer, highlighted the efficient application of miRNAs-based therapies for pancreatic cancer in animal models and clinical trials, and proposed future prospects. This review focuses on the promise of integrating miRNAs into the treatment of pancreatic cancer and provides guidance for the development of precision medicine for pancreatic cancer.

Value of nasobiliary cholangiography in the diagnosis of residual common bile duct stones after endoscopic retrograde cholangiopancreatography and related factors of residual common bile duct stones / 临床肝胆病杂志

ObjectiveTo investigate the value of nasobiliary cholangiography in the diagnosis of residual common bile duct stones after endoscopic retrograde cholangiopancreatography (ERCP) and the risk factors for residual stones. MethodsA retrospective analysis was performed for the clinical data of the patients who underwent ERCP and nasobiliary cholangiography after endoscopic nasobiliary drainage in Peking University First Hospital from January 1, 2018 to December 31, 2019. The chi-square test was used for comparison of categorical data between groups, and a logistic regression analysis was used to investigate independent risk factors for residual stones. ResultsA total of 366 patients underwent ERCP and nasobiliary cholangiography and 27 patients were suspected to have residual stones, among whom 25 had residual stones confirmed by ERCP. The rate of residual stones after ERCP was 6.8% (25/366), and nasobiliary cholangiography had a positive predictive value of 92.6% (25/27) in predicting residual common bile duct stones. The univariate analysis showed that there were significant differences between the two groups in multiple stones, common bile duct diameter ≥1.5 cm, and mechanical lithotripsy (χ2=5014, 7.651, and 9.670, all P＜0.05). The multivariate logistic regression analysis showed that multiple stones (odds ratio ［OR］=2713, 95% confidence interval ［CI］: 1.002-7.345, P=0.049) and mechanical lithotripsy (OR=9.183, 95% CI: 2.347-35.925, P=0.001) were independent risk factors for residual stones. ConclusionPost-ERCP nasobiliary cholangiography is an effective method to detect residual common bile duct stones. Multiple stones and mechanical lithotripsy during ERCP are independent risk factors for residual stones.

Evaluation of neoadjuvant therapy for pancreatic cancer: is it the best choice? / 中华消化外科杂志

Currently the treatment strategy of pancreatic cancer has shifted from the mode "surgery first" to multidisciplinary team.More and more evidences have revealed that neoadjurant therapy will help to increase the R0 resection rate,reduce the recurrence rate,and improve the prognosis of the patients with borderline resectable pancreatic cancer.Furthermore,neoadjuvant therapy is also recommended for resectable pancreatic cancer patients with high risk factors of tumor recurrence.In this article,the current controversy and research progress of neoadjuvant therapy for pancreatic cancer are reviewed and commented in order to deepen the understanding of the hot topic in clinial surgeons.

Evaluation of neoadjuvant therapy for pancreatic cancer: is it the best choice? / 中华消化外科杂志

Currently the treatment strategy of pancreatic cancer has shifted from the mode "surgery first" to multidisciplinary team. More and more evidences have revealed that neoadjuvant therapy will help to increase the R0 resection rate, reduce the recurrence rate, and improve the prognosis of the patients with borderline resectable pancreatic cancer. Furthermore, neoadjuvant therapy is also recommended for resectable pancreatic cancer patients with high risk factors of tumor recurrence. In this article, the current controversy and research progress of neoadjuvant therapy for pancreatic cancer are reviewed and commented in order to deepen the understanding of the hot topic in clinial surgeons.

Current research status and progress in comprehensive diagnosis and treatment of pancreatic cancer in the era of targeted therapy / 中华外科杂志

The incidence of pancreatic cancer (PC) has continuously shown an upward trend all over the world. It remains one of the most challenging malignant tumors in clinical practice and is characterized by difficult diagnosis in early stages, low surgical resection rate and poor prognosis. Due to its significant genetic heterogeneity, there are notable individual differences in disease progression, clinical efficacy, sensitivity to chemoradiotherapy, and prognosis among PC patients. In-depth study is needed to reveal the molecular biological characteristics of different PC subtypes and their correlation with clinical manifestations and chemoradiotherapy sensitivity, which could contribute to develop corresponding targeted therapeutic strategies.It is not only the fundamental basis for the innovation of PC morphological classification to molecular subtyping, but also a prerequisite for achieving a shift in treatment mode from "standard therapeutic strategy for different diseases" to "treat the same disease with different strategies" .This article reviews several hot issues on the comprehensive diagnosis and treatment of PC in the era of targeted therapy and prospects its future development.

Thinking in the confusion, advancing in the challenges:hotspots in the comprehensive treatment of pancreatic carcinoma / 中华消化外科杂志

Pancreatic carcinoma has the poorest prognosis in all the digestive cancers,and the management remains challenging.Nowadays the treatment strategy of pancreatic carcinoma has been changed from "surgery first" into the mode of multi-disciplinary team (MDT) with surgery as a leading and crucial position.By historical review,some issues related to the strategy of borderline resectable pancreatic carcinoma,including value of neoadjuvant therapy,perioperative complications,laparoscopic pancreaticoduodenectomy were discussed and commentated.The breakthrough for managing pancreatic carcinoma will be based on early diagnosis and the development of biologic targeting therapy.The surgeons' concept should constantly advance with the times,and the strategy pattern should be converted from local to system,from morphology to biology,and from surgery to oncology.

Current research status and progress in molecular subtyping of pancreatic cancer / 中华消化外科杂志

Rational molecular subtyping of pancreatic cancer based on genome,transcriptome,proteomics and metabolomics data,in combination with systematic biological analysis,have greatly enriched the traditional histopathological typing methods based on morphology.The introduction of molecular subtyping reflects the progress in deep understanding of the essence of tumorigenesis of pancreatic cancer,providing a necessary foundation for the development of molecular targeted therapy and implementation of precision medicine.Therefore,molecular subtyping of pancreatic cancer has broad application prospects.The current article reviews the current research status and recent progress of molecular subtyping of pancreatic cancer,and discusses the clinical significance of different subtyping methods.

Application and thinking of the concept of enhance recovery after surgery in pancreatic surgery / 临床肝胆病杂志

In recent years, the concept and clinical path of enhanced recovery after surgery (ERAS) have been widely accepted and applied in clinical practice in China, and it is gradually used in the field of pancreatic surgery. Objective factors such as complexity of disease, difficulties in pancreatic surgeries, and a high incidence rate of postoperative complications have led to the great difference in the clinical application of ERAS concept across pancreas centers, and the application and implementation of related clinical paths in this field is still late than that in other disciplines. At present, there is still a lack of high-level evidence for the application effect of the ERAS concept in pancreatic surgery, and high-quality clinical trials are needed to confirm its safety and efficacy. This article reviews the feasibility of the implementation of ERAS in pancreatic surgery and other hot topics, so as to provide a reference for the research in this field.

The effect of standardized lymphectomy and sampling of resected lymph nodes on TNM staging of resectable pancreatic head cancer / 中华外科杂志

Objective@#To examine the effect of standardized lymphectomy and sampling of resected lymph nodes (LN) on TNM staging of resectable pancreatic head cancer.@*Methods@#Consecutive patients with resectable pancreatic head cancer who received standard pancreatoduodenctomy at Department of General Surgery in Beijing Hospital from December 2017 to November 2018 were recruited as study group. After operation, the surgeon sampled lymph nodes from the fresh specimen following the Japanese Gastric Cancer Guidelines.Thirty-three cases were recruited in the study group and the mean age was (59.8±15.2) years.Pathologic reports from December 2015 to November 2016 were taken as control group, containing 29 cases with age of (57.0±13.0) years. Number of lymph nodes, standard-reaching ratio and positive nodes ratio were compared between two groups. According to the seventh edition and eighth edition of TNM staging, the changes of N staging and TNM staging were analysed. The quantitative data conforming to normal distribution were tested by independent sample t test, the quantitative data not conforming to normal distribution were tested by rank sum test, and the enumeration data were analysed by χ2 test.@*Results@#The basal data of the two groups were comparable (all P>0.05) . The number of lymph nodes sampled in the study group was 23.27±8.87, significantly more than in control group (12.86±5.90, t=0.653, P=0.000) .Ratio of cases with more than 15 nodes was 81.8% (27/33) in the study group and 34.5% (10/29) in the control group with statistical significance (χ2=14.373, P=0.000) . In the study group, the positive lymph node ratios of No. 17a+17b, 14a+14b, 8a+8p LN were 36.4% (12/33) , 30.3% (10/33) and 9.1% (3/33) respectively. The positive lymph node ratio in No.14a+14b LN was higher than in No.8 LN (χ2=4.694, P=0.030) . According to the change in N staging system in the AJCC eighth edition, 2 cases (6.1%, 2/33) changed from ⅠB to ⅡA, 7 cases (21.2%, 7/33) from ⅡA to ⅠB and 5 cases (15.2%, 5/33) changed from ⅡB to Ⅲ (25.0%, 5/20) .@*Conclusions@#No.14 LN should be treated as the first station rather than second station because of the anatomic character and higher metastatic ratio. Standardised lymphectomy and sampling may increase the number of LN resected and improve the TNM staging of resectable pancreatic head cancer.

Circulating tumor cells in pancreatic cancer patients: progression in the detection methods and clinical application / 中华外科杂志

Circulating tumor cells (CTC) disseminate from primary tumors by undergoing epithelial mesenchymal transition that allow their entry into the circulation to drive metastatic formation in pancreatic cancer patients.Technological advances in detection and characterization of CTC are conducive to the early diagnosis, differential diagnosis, monitoring disease progression and predicating the probability of canceration or the chemotherapeutic efficacy. Nowadays, detection methods of CTC can be based on immunomagnetic beads technique, cell filtration or microfluidic chips technology, but there are great differences in the sample throughput, CTC recovery rate, purity, and CTC viability among them.Owing to the dilemma in detection methods, the intrinsic relevance between the biological characteristics of CTC and clinical manifestations is still not exactly elucidated. By the improved methodology, next generation sequencing technology and exploring the technique for culturing CTC in vitro and establishing xenotransplanted tumor model in nude mice, more and more biological information will be revealed, and finally, individualized treatment is achieved.

Diagnosis and treatment of pancreatic neuroendocrine neoplasmas in Von Hippel-Lindau syndrome / 中华外科杂志

Von Hippel-Lindau(VHL) syndrome is a rare autosomal dominant hereditary disease, and pancreas is one of the frequently involved intra-abdominal organs, including simple pancreatic cysts, pancreatic serous cystadenomas and neuroendocrine neoplasmas. Most of the VHL-related pancreatic neuroendocrine neoplasmas (VHL-pNEN)were non-functional, but they still have a tendency to be malignant. Treatment options for VHL-pNEN include regular follow-up, surgical resection, and medication therapy. When compared with sporadic pNEN, the malignant degree of VHL-pNEN is lower, with a better prognosis, so the surgical treatment should be carefully considered. The indications of surgery for VHL-pNEN include big primary lesions (≥3 cm), fast tumor doubling time (<500 days), VHL gene mutation on exon 3, malignant manifestations on imaging findings, and functional pNEN lesions. The function-preserving approach should be performed to keep the functional pancreatic parenchyma as much as possible. Even for patients with a late stage malignancy that cannot be radically resected, active medication therapy may still lead to a long-term survival.