Pancreatic fistula after pancreaticoduodenectomy: Risk factors and preventive strategies

Purpose: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. This study aimed to investigate the risk factors and preventive strategies for POPF after PD. Materials and Methods: We retrospectively reviewed 301 consecutive patients who underwent PD at our hospitals between January 2011 and December 2017. We analyzed the pancreatic fistula rate according to the clinical characteristics, pathologic and laboratory findings, and the anastomotic methods and summarized the prevention measures. Results: Postoperative morbidities included pancreatic leakage in 10.30% (31/301), delayed gastric emptying in 22.92% (69/301), abdominal infection in 6.98% (21/301), post-PD hemorrhage in 4.65% (14/301), and bile leakage in 4.98% (15/301), and the mortality rate was 2.33% (7/301). POPF was the most prominent factor for preoperative morbidity. Significant risk factors for pancreatic fistula were a soft pancreas, small pancreatic duct, tumor location, and interrupted anastomosis. Of these, soft texture, pancreatic duct <4 mm, and end-to-end anastomosis through hand suture closure were independent risk factors on multivariate analysis, while interrupted anastomosis, internal stent, and somatostatin use were risk factors in the high-risk pancreas subgroup. Conclusions: Our study demonstrated that pancreatic fistula is related to a soft texture and small pancreatic duct. The surgeon must consider these risk factors when performing PD. Thus, we propose a risk- and indication-adapted choice of anastomosis or an individualized approach for the pancreatic remnant to reduce the pancreatic fistula rate

Effect of Compound Zhajin Granule on Toll-like Receptor 4 Signaling Pathway in Nonalcoholic Steatohepatitis Mice / 中国中西医结合杂志

<p><b>OBJECTIVE</b>To observe the effect of Compound Zhajin Granule (CZG) on Toll-like re-ceptor 4 (TLR4) signaling pathway in high-fructose corn syrup induced NASH mice.</p><p><b>METHODS</b>Thirty 6-week-old male C3H mice were divided into the high fat and high fructose (HFHFr) group (n = 20) and the control group (n = 10) according to body weight. Mice in the HFHFr group ate high fat diet and drank 20% fructose water, while those in the control group ate common diet and drank common water. After 8 weeks mice in the HFHFr group were divided into two group according to body weight, the HFHFr group and the CZG group, 10 in each group. Mice in the CZG group were fed with high fat forage and 20% fructose water, and administered with 50 mL/kg 12. 8% CZG (prepared by hawthorn, Radix Curcumae, Alisma Orientale, Fritillaria Thunbergii, Silybum Marianum, peach seed in the ratio of 3:1.5:1.5:2:1.5:2:1) by gastrogavage. Mice in the HFHFr group were fed in the same way and daily administered with equal volume of distilled water by gastrogavage. Sixteen weeks later all mice were sacrificed. Body weight, liver wet weight, liver function, and lipid metabolism were detected. Pathological changes of liver tissues were assessed by HE staining, oil red O staining, and Masson staining. Expressions of TLR4, myeloid differentiation factor 88 (MyD88), tumor necrosis factor-alpha (TNF-α) were detected using immunohistochemical staining and real-time fluorescent quantitative PCR.</p><p><b>RESULTS</b>Body weight, alanine aminotransferase (ALT), aspartate aminotransferase (AST) were obviously lower in the CZG group than in the HFHFr group (P < 0.05); oil red O stained area and density were decreased more in the CZG group than in the control group. HE staining showed ballooning inflammation was reduced more in the CZG group than in the HFHFr group. Masson staining was negative. Positive rates of TLR4 and MyD88 and mRNA expressions were significantly lower in the CZG group than in the HFHFr group (all P < 0.05).</p><p><b>CONCLUSION</b>CZG could significantly inhibit TLR4 signaling pathway of liver in NASH mice.</p>

The effect of RNA interfering TLR4 signal pathway on phagocytosis of Kupffer cells / 中华实验和临床病毒学杂志

<p><b>OBJECTIVE</b>To investigate the effect of RNA interfering TLR4 signal pathway on phagocytosis of Kupffer cells.</p><p><b>METHODS</b>RAW2647 mice mononuclear macrophage leukemia cells were observed. The tested group was interfered by Tlr4-mus-1567 RNA which had the best result confirmed by QPCR, cells interfered by Negative Control RNA as NC group, and normal cell as control. We perform the phagocytosis test on each group.</p><p><b>RESULTS</b>The tested group has lower phagocytes percentage than control (17.67% +/- 3.51% vs 32.00% +/- 3.00%, P < 0.01), and lower phagocytic index (46.33% +/- 7.51% vs 82.00% +/- 6.08%, P < 0.01).</p><p><b>CONCLUSIONS</b>Decreased phagocytic activity was observed on Kupffer cells by RNA interference.</p>

Activation of Kupffer cell and related signal pathway proteins in the liver of high fat and high fructose diet induced NAFLD mice / 中华实验和临床病毒学杂志

<p><b>OBJECTIVE</b>To investigate the expression of F4/80, NF-kappaB, p-AKT, AKT in the liver of nonalcoholic fatty liver disease (NAFLD) mice. To determine the role of Kupffer cells (KCs) in the development of NASH (non-alcoholic steatohepatitis), and understand the pathogenic mechanism of NASH.</p><p><b>METHODS</b>Five C3H/HeN mice fed with normal diet were served as controls, while fifteen fed with high fat, high fructose, high fat combined fructose diet respectively for 16 weeks were as NAFLD mice models. The liver inflammation and hepatic damage were examined, and the expression of F4/80, NF-Kb, p-AKT, AKT and the content of lipid in the liver were also detected.</p><p><b>RESULTS</b>Chronic intake of high fat and 30% fructose solution caused a significant increase in hepatic steatosis in animals in comparison to water controls. Liver F4/80 and NF-kappaB were significantly higher in high fat and high fat combined fructose diet fed mice than that in controls (P < 0.01, P < 0.01), F4/80 protein were higher in high fat diet treated mice than those in fructose and high fat combined fructose groups (P < 0.01, P < 0.01). Markers of insulin resistance (e. g, hepatic phospho-AKT, AKT) were only altered in fructose-fed or high fat combined fructose animals (P < 0.01, P < 0.01).</p><p><b>CONCLUSION</b>High fat and fructose diet may induce NAFLD in C3H/HeN mice. Kupffer cells and signal pathway proteins were activated, and they may play key roles in the initiation and progression of NASH.</p>

Protective effects of rhein on hepatic progression in HBV-transgenic mice with nonalcoholic steatohepatitis induced by a high-fat diet / 中华实验和临床病毒学杂志

<p><b>OBJECTIVE</b>To investigate the beneficial effects of Rhein (RH) on hepatic progression in hepatitis B virus (HBV)-transgenic mice with nonalcoholic steatohepatitis induced by a high-fat (HF) diet.</p><p><b>METHODS</b>A mice model of HBV chronic infection concomitant with liver steatosis was induced by a HF diet in 4-week old HBV-transgenic mice for 16 weeks (n = 130). Thereafter, the mice were divided randomly into control group (back to normal chow), model group (continuing HF diet), RH group [continuing HF diet and administering with 120 mg/(kg x d) RH by gavage] and Essentiale group [continuing HF diet and administering with 69.2 mg/(kg x d) Essentiale by gavage] with 30 mice in each, and were sacrificed at the end of 24-week and 48-week respectively. Serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total cholesterol (TC), triglyceride (TG) and fasting plasma glucose (FPG) were measured by an automatic biochemical analyzer, and serum HBV-DNA was determined with qPCR. Hepatic histology was evaluated by HE staining with a light microscope.</p><p><b>RESULTS</b>(1) An histological change composed of steatosis, lymphocytes intralobular infiltration and ballooning was observed after 48 weeks feeding of HF diet, in part mimicking that of NASH patients as evidenced by a NAFLD activity score (NAS) of 3.58 +/- 1.44 points. (2) Histologically, the NAS of model group was higher than that of control group at both time points. RH failed to lessen NAS whereas Essentiale improved the NAS at 48-week. (3) Serum levels of TC, TG and FPG were significantly different between 4 groups at 24-week, with a comparable low value in both RH and Essentiale group. A similar change was evident at 48-week. (4) In terms of HBV viral load, a significantly lower level in Essentiale group than the others was observed at both time points.</p><p><b>CONCLUSION</b>HF diet feeding is able to induce a mouse model of HBV chronic infection concomitant with NASH. RH is effective in alleviating the glucose and lipid metabolism but ineffective in improving the hepatic histology in this model, in contrast, backing to normal chow achieved a better effect in this aspect.</p>

Model building-up and observation on the mouse carried chronic hepatitis B and nonalcoholic fatty liver disease / 中华实验和临床病毒学杂志

<p><b>OBJECTIVE</b>Establish the model of mouse with chronic hepatitis B virus (HBV) and nonalcoholic fatty liver disease (NAFLD).</p><p><b>METHODS</b>Take 100 HBV transgenic, BALB/c mice of 4 weeks old, with each gender half. Then pick out 70 mice in one group to feed high-fat feed and the rest to feed normal feed. At the end of week 16, random kill 10 mice of high-fat, then liver tissue and serological detection target identification model is established in this paper. After that, divide the mice into model group and comparison group with 30 mice in each group. Feed model group with high-fat feed, comparison group with normal feed and normal group with normal feed till week 72 (including previous 16 weeks). Kill 10 mice of each group at the end of week 24, 48 and 72 respectively, fully automatic biochemical instrument detection of serum ALT, AST, TC, TG, FBG, fluorescence quantitative PCR method to detect HBV-DNA, chemiluminescence detection of HBsAg, liver biopsy after HE staining to evaluate histology change, observe mice model of dynamic evolution.</p><p><b>RESULTS</b>(1) Feed high fat feed after 16 weeks, mice's weight, serum ALT, AST, TC, TG, FBG and blood biochemical indicators increased, HBV-DNA positive, liver HE staining obviously big blister fatty degeneration of liver cells and within the lobule lymphocytes infiltration, NAFLD activity score (NAS) getting close to NASH, the model of chronic HBV carries with NAFLD mouse built successfully. (2) The TC and TG values of model group in each period were higher than that of comparison group and normal group. (3) In week 24 and 72, HBV-DNA values of each group are obvious different from the other two groups and the difference can be applied to statistical significance (P < 0.05). (4) In week 48 and 72, NAS of each group are obvious different from the other two groups and the difference can be applied to statistical significance (P < 0.05).</p><p><b>CONCLUSIONS</b>(1) Chronic HBV carries with NAFLD mice model can be established by HBV transgenic mice fed by high fat feed. (2) NAFLD accelerates the liver disease of the mice carrying HBV to some extent.</p>

Optimal technique of three-dimensional MRI of the lumbar nerve root and its radicular vein in normal and lumbar disc herniation patients / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Although three-dimensional MRI (3D-MRI) of short T1 inversion recovery turbo spin-echo (STIR TSE) has showed superior to two-dimensional MRI (2D-MRI) in showing the spinal cord and lumbar nerve roots, it remains difficult in demonstrating radicular vein at present. We have found that short T1 inversion recovery long time echo (STIR LONG TE) was better in showing radicular vein. To further study the methods and character of the 3D-MRI of lumbar nerve root, ganglions and radicular vein in normal and lumbar disc herniation (LDH) adults, in the present study, we evaluated two 3D-MRI techniques, STIR TSE and STIR LONG TE for demonstrating lumbar nerve roots and especial radicular vein in normal and LDH adults.</p><p><b>METHODS</b>Twelve normal adult persons and 19 LDH patients were included in this study; special oblique coronal location was adopted. STIR TSE and STIR LONG TE were performed in all participants, and the detection rates of radicular vein and nerve root of L3, L4, L5, S1 were calculated. The grading system was used in grading compromise of the intraspinal extradural lumbar nerve root, ganglion and radicular vein in LDH patients, and all the grading injury of nerve root, ganglion and radicular vein had been evaluated.</p><p><b>RESULTS</b>The definite rate of radicular vein (DRRV) of 3D-MRI of STIR LONG TE was significantly different from that of STIR TSE. DRRV of STIR LONG TE was L3, 91.7%, L4, 100%, L5, 100%, S1, 100% and that of STIR TSE was L3, 33.3%, L4, 37.5%, L5, 58.3%, S1, 45.8% in normal adults. It showed no difference between STIR LONG TE and STIR TSE in the detection rate of nerve root. The different patho-injuries of nerve root, ganglion and radicular vein could be seen in all LDH patients by the 3D-MRI of STIR LONG TE. The mean score of Japanese Orthopaedic Association (JOA) was 16.16, and 29 nerve roots were calculated in all the study. The mean grading injury of nerve root was 2.17, that of nerve root ganglion was 1.28, that of radicular vein was 1.83, and the mean co-grading injury of nerve root, ganglion and radicular vein was 5.31. The correlation coefficient was 0.478 (P = 0.010) between the score of JOA and that of radicular vein.</p><p><b>CONCLUSION</b>The 3D-MRI of STIR LONG TE is superior to STIR TSE for not only detecting the lumbar nerve root, ganglion and especial radicular vein in normal adults, but also displaying their patho-injuries degree in LDH patients.</p>

The accuracy of myocardial perfusion imaging using quantitative analysis for patients with coronary artery disease: a Chinese hospital experience / 中华核医学杂志

Objective To evaluate the accuracy of automated quantification of myocardial perfusion imaging (MPI) using a method based on a Western normal database for the detection of coronary artery disease (CAD) in a group of Chinese patients. Methods Seventy-two Chinese patients who underwent coronary angiography (CAG) and MPI within 3 months were recruited into this study. Eighty selected from 140 Chinese patients with low probability of CAD ( ＜ 5% ) were enrolled into local normal database of 99Tcm-methoxyisobutylisonitrile (MIBI) MPI using Cedars quantitative perfusion SPECT (QPS) database. Two Western MPI normal databases (CSMC MibiMbiAuto and Mibimibi) were used for processing the Chinese CAD patients recruited in this study, and the results were compared with those using local normal database and visual interpretation. T-test and z-test were used for statistical analysis. Results The extent (EXT)measurement obtained from Mibimibi and local database was ( 10.73 ± 14.54)% and ( 14.22 ± 16.51 )%,respectively ( t = 7.87, P ＜ 0.001 ); the severity (SEV) was 1.07 ± 0.93 and 1.34 ± 1.20, respectively ( t =7.45, P＜0.001). The area under curve(AUC) by using EXT measurement for local database (0.85 ±0.05) was larger than that for CSMC MibiMbiAuto ( AUC = 0.72 ± 0.06, z = 2.50, P ＜ 0.01 ) and Mibimibi ( AUC = 0.77 ± 0.06, z = 2.47, P = 0.014). The AUC of local database showed no significant difference from that of visual interpretation (AUC=0.83 ±0.05, z=0.05, P＞0.05). Conclusion Quantification of MPI of our Chinese patients using Western normal database would decrease the accuracy for the detection of CAD.

Diagnostic value of multi-slice spiral CT three dimensional reconstruction in maxillofacial diseases / 中国医学科学院学报

<p><b>OBJECTIVE</b>To evaluate the diagnostic value of multi-slice spiral CT (MSCT) three dimensional (3D) reconstruction for maxillofacial diseases.</p><p><b>METHODS</b>Sixty patients with maxillofacial diseases underwent the scanning of MSCT with 3D reconstruction. Among them, 34 patients with maxillofacial fracture, 10 patients with maxillofacial tumors and tumor-like diseases, and 16 patients with congenital deformities. The MSCT scanned with slice thickness of 2 mm. The methods of 3D reconstruction included multi-planar reconstruction (MPR), shaded surface display (SSD), and volume rendering (VR). The results were compared with what was observed during operations.</p><p><b>RESULTS</b>Totally 36 cases of maxillofacial fracture were shown by 2D or 3D imaging and were validated by the observations during operation. The MSCT with 3D reconstruction imaging was significantly superior to 2D axial imaging in maxillofacial fracture. Three dimensional imaging could clearly show the spacial anatomy of facial, fragment displacement, and tracing fracture lines. However, 2D imaging had better effectiveness than 3D imaging in observing deep structure and fine fracture. In maxillofacial tumors and tumor-like diseases, 3D imaging was significantly superior to 2D axial imaging in showing the tumor shape and spacial relationships between tumors and surrounding structures. Two dimensional imaging and MPR imaging were excellent to reveal internal structure and pathological changes of tumors. 2D imaging and MPR imaging also achieved better results in showing tumors extended to soft tissues. In maxillofacial congenital deformities, 3D imaging were superior than 2D imaging.</p><p><b>CONCLUSION</b>3D imaging has an important value in the diagnosis and clinical assessment of maxillofacial fracture, tumor-like diseases, and congenital deformities.</p>

Magnetic resonance imaging of lymph node metastasis in nasopharyngeal carcinoma / 中华放射肿瘤学杂志

Objective To explore the distribution rule of metastatic lymph node in nasopharyngeal carcinoma (NPC) by magnetic resonance imaging (MRI).Methods 315 histopathologically proved NPC patients were studied retrospectively.All patients had had their nasopharynx scanned by MRI with plain and contrast enhanced sequences.The distribution of lymph node was divided into six cervical levels plus retro- pharyngeal nodes(RN) according to RTOG guidelines proposed in 2003.Results 254 out of 315 patients (80.6%) had lymph node involvement,with 81 in the right neck alone,72 left neck alone,and 101 both necks;73 in RN alone,21 neck node alone,and 160 both necks and RN node.Skip metastasis was found in only 4 patients (1.6%).There was significant difference in BN metastasis between the primary tumor be- ing located merely on the superior/posterior wall and lateral wall (78% vs 49%,P＜0.01).The incidence of lymph node metastasis in T1,T2,T3 and T4 patients was 73.5%,91.2%,71.9%,73.5% (P＞0.05), respectively,without significant difference between early or advanced T stage in node distribution (P＞0.05).Conclusions The incidence of lymph node metastasis is high in nasopharyngeal carcinoma,with retropharyngeal node being the most commonly involved,but the incidence of skip metastasis is very low. There is no significant difference between T stage and the incidence of lymph node metastasis.So is the dis- tribution of metastatic node.

Morphological evaluation of lumbar dorsal root ganglion on three-dimensional magnetic resonance imaging / 中华放射学杂志

Objective To investigate the morphological features of normal lumbar dorsal root ganglia using a three-dimensional(3D)coronal MR imaging.Methods One hundred and fifteen volunteers were included.Ages ranged from 15 to 75 years,with a mean of 40 years.Coronal 3D fast field echo(FFE) with water selective excitation(Proset)MR examination of 1150 dorsal root gangha were underwent at nerve root levels from L1 to L5.The source coronal images were further reconstructed into a series of rotational alignment coronal images with an interval angel of 12 degree using maximum intensity projection(MIP) technique.All DRGs of bilateral spinal nerve from L1 to L5 were morphologically analyzed on the original and MIP images including qualitative evaluation of the location,signal intensity,architecture and quantitative dimensional measurement.Results There were 225,225,219,210 and 160 foraminal ganglia from L1 to L5 level,respectively.The incidence of intraspinal ganglia from L3 to L5 gradually increased with a maximum at L5 level of 29.1%(X~2=188.371,P

Imaging diagnosis of aneurysmal bone cyst secondary to giant cell tumor / 中华放射学杂志

Objective To improve recognition and imaging diagnosis of aneurysmal bone cyst secondary to a giant cell tumor.Methods To collect the dates of 12 patients with aneurysmal bone cyst secondary to a giant cell tumor were proved by operation and pathology from January 2003 to October 2006. Analyzed and summarized their imaging manifestations and correlation with pathohistology.Results Six lesions were located in epiphysis and metaphysic regions of long bone.Six lesions were located in pelvis.All cases showed a cystic lesion with expanded and osteolytic,eccentric 10 cases and centric 2 cases.Four cases display trabeculate,the margin is well define with a rim of bone sclerosis in 2 cases.Magnetic resonance imaging(MRI)scans were available in 10 patients.All case showed cystic,dilated lesions with solid areas. Eight cases manifested single or multitude solid nodules in big cystic wall.Two cases appeared solid masses with multitude cysts.The sign of multitude fluid-fluid level,best seen on T_2-weighted images,was present in all patients.Seven cases emerged soft-tissue masses.MR found indicative of large amounts of hemosiderin in one cases.Eight cases were examined by spiral CT with plain scanning and enhancement scanning. Reconstructed image were CTA and 3D-MPR(three dimensions multiplanar reconstruction)imaging.All cases showed cystic,dilated lesions with solid areas.The sign of multitude fluid-fluid level was present in 6 patients.The solid areas and cystic-wall of lesions showed contrast enhancement in 8 patients.3D-MPR imaging showed supply blood vessel of tumors in 3 cases.Arteriovenous malformation did not found in all patients.The surgeons'operative findings and the gross specimens were studied in all patients.All lesions were composed of solid areas and cystic areas.The diagnosis of pathology were ABC with GCT(grade Ⅱ)in 10 cases and ABC with GCT(grade Ⅲ).Conclusion Aneurysmai bone cyst secondary to a giant cell tumor is not rare.Adequately recognizing the pathologic basis of ABC,and selecting imaging techniques correctly (X-ray and MRI,or X-ray and CT)is especially important to diagnose a giant-cell tumor with secondary aneurysmai bone cyst.When an eccentric,expanded,lytic tumor with a cystic-solid lesion in epiphysis of long bone or pelvis shows multiple fluid levels,a giant-cell tumor with secondary aneurysmai bone cyst components should be sufficiently considered.

Evaluation of brachial plexus injury by MRI / 中华放射学杂志

Objective To evaluate the diagnostic value of MRI in brachial plexus injury.Methods Total 98 patients with brachial plexus injury were examined by MRI before operation.Fifty-four of 98 patients MR imaging were obtained by 0.5 Tesla scanner and other 44 patients were obtained by 1.5 Tesla scanner.The scanning sequences include: SE T_1WI,T_2WI,FFE T_2WI and T_2WI SPIR. Exploration of the supraclavicular plexus was carried out and the MR imaging were compared with the operative finding in 63 patients.Thirty-five patients who had not surgery were followed-up.Results MR imaging found pre-ganglionic injuries in 45 patients and post-ganglionic injuries in 56 patients.Pre-and post-ganglionic injuries simultaneously in 16 patients among them.MR imaging can not find injury sings in 13 patients.The positive rate was 86.73%.MR imaging finding of pre-ganglionic injuries include:(1) Spinal cord edema and hemorrhage,2 patients (4.44% ).(2)Displacement of spinal cord,17 patients (37.78%).(3)Traumatic meningoceles,37 patients (82.22%).(4)Absence of roots in spinal canal, 25 patients(55.56% ).(5)Scarring in the spinal cnanl,24 patients (53.33%).(6)Denervation of erector spine,13 patients (28.89%).MR imaging finding of post-ganglionic injuries include:(1)Trunk thickening with hypointensities in T_2WI,23 patients (41.07%).(2)Nerve trunk complete loss of continuity with disappeared of nerve structure,16 patients (28.57%).(3)Continuity of nerve trunk was well with disappearance of nerve structure,14 patients(25.00%).(4)Traumatic neurofibroma,3 patients (5.36%).Conclusion MR imaging can reveal Pre-and post-ganglionic injuries of brachial plexus simultaneously.MR imaging is able to determine the location (pre-or post-ganglionic)and extent of brachial plexus injury,provided important information for treatment method selection.