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Objective:To analyze the risk factors of clinically significant bleeding in patients with severe acute pancreatitis (SAP).Methods:The clinical data of SAP patients who were managed at Changhai Hospital affiliated to Naval Medical University from January 1, 2014 to October 31, 2022 were retrospectively analyzed. Twenty-nine SAP patients with clinically significant bleeding were classified to form the bleeding group. There were 23 males and 6 females, aged (56.25±14.01) years old. Another 116 SAP patients with similar general data but with no clinically significant bleeding during the same hospitalization period were included to form the non-bleeding group based on a ratio of 1∶4. There were 94 males and 22 females, aged (56.14±13.96) years old in this non-bleeding group. The general data, modified CT severity index (MCTSI), bedside index for severity of acute pancreatitis (BISAP) and other clinical data of the two groups were collected to determine the risk factors of bleeding in SAP patients.Results:Of the 29 patients with bleeding, 6 had gastrointestinal bleeding, 14 had intra-abdominal bleeding, and 9 had mixed bleeding sites, 15 were cured and discharged, and 14 died. All the 29 SAP patients with bleeding received treatment using drugs. In addition, 8 patients underwent successful hemostasis using digital subtraction angiography, 3 underwent successful endoscopic hemostasis, 2 underwent successful surgical hemostasis, and 2 underwent successful conservative drug hemostasis. Multivariate logistic regression analysis showed that SAP patients with higher MCTSI ( OR=1.824, 95% CI: 1.187-2.802), longer prothrombin time (PT) ( OR=3.431, 95% CI: 1.470-8.007) and higher BISAP ( OR=2.286, 95% CI: 1.054-4.957) had an increased risk of bleeding (all P<0.05). Conclusion:The prognosis of SAP patients was compromised with bleeding. High MCTSI, prolonged PT, and high BISAP were independent risk factors for bleeding in SAP patients.
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Objective:To analyze the clinical features of post-pancreaticoduodenectomy hemorrhage, and explore effective and practical nursing strategies.Methods:Clinical data of 62 patients with post-pancreaticoduodenectomy hemorrhage from Jan 2014 to Dec 2019 in the First Affiliated Hospital of Naval Medical University were retrospectively analyzed. The bleeding time, location, vital signs, accompanying symptoms and surgical treatment measures and clinical outcomes were analyzed.Results:Among the 62 cases, early (within 24 h) hemorrhage occurred in 19/62 patients (30.6%), and late hemorrhage occurred in 43/62 patients (69.4%). 36/62 patients (58.1%) had arterial bleeding; And 43/62 patients (69.4%) had abdominal hemorrhage. Grade C hemorrhage occurred in 32/62 patients (51.6%). Sentinel hemorrhage occurred in 8/62 patients (12.9%). The manifestation of hemorrhage in 42 patients was bloody fluid from abdominal drainage tube (67.7%). Hemorrhage occurred in 23 patients with pancreatic fistula(37.1%), 12 patients with abdominal infection and other complications (19.4%). Shock symptoms occurred in 41 cases (66.1%) with postoperative hemorrhage. Pancreaticoduodenectomy hemorrhage were early detected in 0.3 h and last detected in 869 h, with a median time of 192.00 (14.63, 297.00) h. 30/62 cases (48.4%) of hemorrhage patients occurred 1 hour before and after nursing shift. When hemorrhage was found, emergency treatments such as blood transfusion to maintain blood volume ( n=47, 75.8%), hemostasis ( n=35, 56.5%) and vasoactive drugs to increase blood pressure ( n=32, 51.6%) were usually given immediately. 31/62 patients (50.0%) underwent emergency secondary surgery within 4 h of hemorrhage, and 45/62 patients (72.6%) were cured by emergency surgical treatment. A written treatment pre-plan for surgical nurses was established. Conclusions:Surgical nurses should be familiar with the clinical manifestations of post-pancreaticoduodenectomy hemorrhage, and improve the alarming ability of identifying the complications of post-operative hemorrhage. The establishment of an emergency pre-plan for surgical nurses could help to treat such patients timely and effectively.
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Objective:To investigate the risk factors for delayed gastric emptying (DGE) following pancreaticoduodenectomy (PD).Methods:Clinical data of 385 patients who underwent PD in Changhai Hospital of Navy Medical University from January 2017 to November 2017 were retrospectively analyzed, including 235 men and 150 women. According to the definition of DGE by the International Study Group of Pancreatic Surgery (ISGPS), patients were divided into-clinically irrelevant DGE (non CR-DGE) group and clinically relevant DGE(CR-DGE) group. Univariate analysis and multivariate logistic analysis were used to identify the risk factors of CR-DGE after PD.Results:Of the 385 patients, 78 cases (20.3%) developed DGE. There were 35 cases of CR-DGE (9.1%). In the multivariate analysis, BMI( OR=1.117, 95% CI1.006-1.240, P=0.038), preoperative serum albumin( OR=0.902, 95% CI 0.832-0.977, P=0.012), the main pancreatic duct diameter (MPD)≤3 mm( OR=2.397, 95% CI 1.016-5.653, P=0.046), soft texture of pancreas( OR=2.834, 95% CI 1.093-7.350, P=0.032), clinically relevant postoperative pancreatic fistula (CR-POPF)( OR=4.498, 95% CI 1.768-11.441, P=0.002) were independent risk factors for CR-DGE after PD. Conclusions:High BMI, low preoperative serum albumin, MPD ≤3 mm, soft texture of pancreas and CR-POPF after surgery were independent risk factors for CR-DGE, and early clinical interventions should be performed.
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Objective:To investigate the expression of tripartite motif 14 (TRIM14) in human pancreatic cancer and analyze its relationship with clinicopathological features and prognosis, and further explore its functional mechanism in the development and progression of pancreatic cancer.Methods:176 pairs of pancreatic cancer tissues and corresponding adjacent tissues resected by surgery in Changhai Hospital affiliated with Navy Medical University from January 2016 to December 2018 were collected. The protein expression of TRIM14 in pancreatic cancer and adjacent normal tissue was detected by immunohistochemical staining. TRIM14 and phosphorylated p65 expression in pancreatic cancer was measured by western blotting. NF-κB targeting gene Bcl-xl, CCND1, VEGF-C mRNA was tested by real time quantitative PCR. The correlation between TRIM14 expression and clinicopathological characteristics was analyzed. The relationship between TRIM14 expression and tumor-free survival and overall survival of pancreatic cancer patients was evaluated by univariate and multivariate Cox regression model. The internal relationship between TRIM14 expression and the activation of NF-κB signaling pathway was analyzed.Results:The positive TRIM14 expression rate in pancreatic cancer was obviously higher than that in adjacent normal tissue [86.93%(153/176) vs 27.27%(48/176)], and the difference was statistically significant ( P<0.05). The expression level of TRIM14 was correlated with the clinical stage, lymph node metastasis and invasion depth of pancreatic cancer ( P=0.000, 0.000, 0.021), but not obviously with gender, age, differentiation degree and distant metastasis. Cox regression analysis showed that the expression level of TRIM14 was the independent risk factor for tumor-free survival ( RR=1.706, 95% CI 1.237-2.429, P=0.029) and overall survival ( RR=1.806, 95% CI 1.984-2.831, P=0.029). The expression level of TRIM14 was tightly associated with the phosphorylation level of p65 ( R=0.86, P<0.01), and the mRNA expression of Bcl-xl, CCND1 and VEGF-C was highly correlated with TRIM14 expression ( R=0.85-0.92, P<0.01). Conclusions:TRIM14 was highly expressed in pancreatic cancer tissues and was an independent risk factor for prognosis of pancreatic cancer patients. TRIM14 participates in the development and malignant progression of pancreatic cancer potentially via activating NF-κB pathway.
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Objective To comprehensively analyse the immunophenotype of primary pancreatic cancer,providing biological clues for treating pancreatic cancer.Methods The genome nap of 177 primary pancreatic cancer patients from the Cancer Genome Atlas (TCGA) database were enrolled.The overall immune infiltration score (IIS),T cell infiltration score (TIS) and antigen presenting machinery (APM) score were quantified for each specimen.By using unsupervised clustering,the patients were divided into immune-high group and immune-low group according to IIS,TIS,and APM scores.The differences on the inffiltration of immune cell subtype,expression of immune checkpoint and immunological function evaluation were compared between two groups.Results In the radiotherapy population,the survival rate of immune-high group was slightly higher than that of immune-low group with no statistical significance.The immune-high group had more infiltrated neutrophils (63.4％ vs 36.6％),eosinophils (75.5％ vs 24.5％),activated CD4 + memory T lymphocytes (80.7％ vs 19.3％),naive CD4 + T lymphocytes (81.2％ vs 18.8％) and naive B lymphocytes (59.5％ vs 40.5％) compared with immune low group;while the immune-low group had more activated NK cells (67.3％ vs 32.7％),regulatory T lymphocytes (68.9％ vs 31.1％),T follicular helper (67.7％ vs 32.3％),and activated mast cells (62.9％ vs 37.1％).Co-stimulatory molecules such as CD28,ICOS,CD40,CD40L,CD27,CD27L,4-1BB,OX40,GITR and co-inhibitory molecules including CTLA-4,PD-L2,PD-1,VISTA,LAG-3,TIGIT,Galectin-9,TIM-3,and IDO-1 were significantly higher expressed in the immune-low group (all P ＜ 0.05).The PC1 value of principal component analysis of chemokine expression levels and the cytolytic activity (CYT) in the immune-high group were significantly higher (all P ＜0.001).Conclusions Clustering on the three inmune quantification scores could be preliminarily used for immunophenotyping pancreatic cancer.The immune-high group may have synergistic effect with radiation therapy.Treatment with immune checkpoint inhibitor may be effective in immune-low group.
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Objective To investigate the clinical efficacy of pancreaticoduodenectomy using artery first approach and prior portal vein (PV)-superior mesenteric vein (SMV) shunting for complicated pancreatic head tumors.Methods The retrospective cohort study was conducted.The clinicopathological data of 91 patients with pancreatic head cancer who were admitted to the Changhai Hospital of Navy Medical University from February 2011 to December 2016 were collected.Among 91 patients undergoing pancreaticoduodenectomy combined with vascular resection and reconstruction,27 using artery first approach and PV-SMV shunting and reconstruction were allocated into the PD-PVR group,23 using conventional approach were allocated into the PD-CVR group,and 41 receiving pancreaticoduodenectomy with vascular resection were allocated into the PD-SVR group.Observation indicators:(1) comparison of intra-and post-operative situations among groups;(2) comparison of postoperative pathological results among groups;(3) comparison of postoperative survival among groups.Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to December 2017.Comparisons among groups of count data were done by the chi-square test or Fisher exact probability.Measurement data with normal distribution were represented as x±s,comparisons among groups were analyzed using the ANOVA,and pairwise comparison was done using the LSD method.Measurement data with skewed distribution were described as M(Q),comparison among groups was analyzed using the Kurskal-Wallis rank sum test,and pairwise comparison was done using the paired comparison with adjusted P value.Ordinal data were compared using the nonparametric test.The survival rate and curve were respectively calculated and drawn by the Kaplan-Meier method,and Log-rank test was used for survival analysis.Results (1) Comparison of intra-and post-operative situations among groups:operation time,time of hepatic inflow occlusion,volume of intraoperative blood loss,cases with intraoperative blood transfusion,length of PV or SMV removal,cases with vascular grafts,grading 1,2,3,4 and 5 of Clavien-Dindo classification of postoperative complications and duration of hospital stay were respectively (274±36)minutes,(22±7)minutes,1 661 mL (110 mL,3 800 mL),20,(5.6±1.4)cm,6,11,1,1,1,1,(20±7)days in the PD-PVR group and (281±41)minutes,(27±5)minutes,1 888 mL (176 mL,4 162 mL),18,(5.4±1.5) cm,3,1,8,2,0,0,(21±7)days in the PD-CVR group and (201± 36)minutes,(16±6)minutes,1052 mL (74 mL,3 926 mL),17,(3.2±2.0) cm,5,15,2,3,1,1,(13± 6)days in the PD-SVR group,with statistically significant differences among groups (F=37.060,34.530,x2=13.771,14.015,F=32.260,x2 =39.309,F =19.880,P＜0.05).Patients with postoperative complications were improved by symptomatic and supporting treatment.(2) Comparison of postoperative pathological results among groups:mnaximum tumour dimension was respectively (3.6± 1.3) cm,(4.0± 1.3) cm and (2.6± 1.3) cm in the PD-PVR,PD-CVR and PD-SVR groups,with a statistically significant difference among groups (F =7.845,P＜0.05).Cases with high-differentiated,moderate-differentiated and low-differentiated tumors of tumor differentiation,staging Ⅱ A and Ⅱ B of tumor staging,nerve invasion,positive lymph node,positive resection margins in neck of pancreas,bile duct and SMV were respectively 0,13,14,17,10,17,21,0,0,0 in the PD-PVR group and 1,12,10,10,13,15,19,1,0,0 in the PD-CVR group and 1,29,11,17,24,30,29,2,1,1 in the PD-SVR group,with no statistically significant difference among groups (x2 =4.122,3.306,0.902,1.214,P＞0.05).(3) Comparisons of postoperative survival among groups:of 91 patients,52 were followed up for 3.0-69.3 months,with a median time of 18.0 months and follow-up rate of 57.1％ (52/91),including 16 in the PD-PVR group and 14 in the PD-CVR group and 22 in the PD-SVR group.The median survival time,1-,2-and 3-year overall survival rates in 52 patients were respectively 16.6 months,63.5％,35.7％ and 26.8％.The survival time in the PD-PVR,PD-CVR and PD-SVR groups were respectively 12.3 months (3.9-69.3 months),15.0 months (3.0-63.3 months) and 20.0 months (6.0-65.2 months),with a statistically significant difference in survival among groups (x2=6.201,P＜0.05),and between PD-PVR and PD-SVR groups (x2 =4.412,P＜0.05).There was no statistically significant difference in survival between PD-PVR and PD-CVR groups (x2 =0.001,P＞0.05).Conclusion Pancreaticoduodenectomy using artery first approach and PV-SMV shunting and reconstruction for complicated pancreatic head tumors can reduce the time of hepatic inflow occlusion,it also contributes to the risk control of surgery for complicated pancreatic tumors,increases surgical safety and improves patients' prognosis.
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Objective@#To compare the clinical therapeutic effects of arterial first approach pancreaticoduodenectomy(AFA-PD) with standard approach pancreaticoduodenectomy(SPD) in the treatment of borderline resectable pancreatic cancer (BRPC).@*Methods@#A retrospective analysis of the clinical data of 113 cases of pancreatic cancer patients from January 2014 to August 2015 at Department of Hepato-Biliary-Pancreatic Surgery, Changhai Hospital, the Second Military Medical University, including 43 cases in AFA-PD group and 70 cases in SPD group.Every patient had gone high-resolusion computed tomography before the surgery, when BRPC was definitely diagnosed by both experienced radiologist and pancreatic surgeon.There were 24 males and 19 females in the AFA-PD group, with average age of (61.6±10.2)years.And in the SPD group, there were 47 males and 23 females, with average age of (62.7±9.4)years.@*Results@#The operation time was (210.7±31.5)minutes in AFA-PD group, (187.9±27.4)minutes in SPD group, and peroperative bleeding volume was (1 007.1±566.3)ml in AFA-PD group, (700.0±390.0)ml in the other group.Those two indicators of AFA-PD group, compared with SPD group, were relatively higher, the difference was statistically significant(all P<0.01). And with regard to postoperative diarrhea(9.3% vs.5.7%), postoperative 1, 3 days of white blood cells(postoperative 1 day: (13.3±1.1)×109/L vs.(12.4±2.4)×109/L; postoperative 3 days: (12.7±1.6)×109/L vs.(11.7±2.5)×109/L), postoperative 1, 3, 5 days of peritoneal drainage fluid volume(postoperative 1 day: (184±42)ml vs.(156±54)ml; postoperative 3 days: (155±48)ml vs.(133±35)ml; postoperative 5 days: (66±20)ml vs.(47±31)ml), the differences between the two groups were statistically significant (all P<0.05). One patient in the SPD group was treated with unplanned secondary surgery for postoperative intraperitoneal hemorrhage, and the patient was cured and discharged.There was no death in the two groups within 30 days after surgical operation and no patient with positive gastric margin, duodenal margin, or anterior margin.The resection rate of superiormesenteric artery(SMA) margin R0 in AFA-PD group was higher than that in SPD group (P=0.019). The two groups were followed up for 14 to 30 months.As for AFA-PD group, the average survival time, progression free survival time and median survival time was respectively (20.4±1.2)months, (21.5±1.4)months and 20 months.There were 3 cases(7.0%) with local recurrence and 8 cases(18.6%) with liver metastasis or distant metastasis.In the SPD group, the average survival time, progression free survival time and median survival time was (17.1±1.1)months, (16.4±1.3)months and 16 months, respectively.There were 13 cases(18.6%) with local recurrence and 25 cases(35.7%) with liver metastasis or distant metastasis.As a result, the AFA-PD group had longer survival time(P=0.001)and progression free survival time(P=0.002). However, the lower local recurrence and distant metastasis rate in AFA-PD group did not reach statistical standard (P>0.05).@*Conclusion@#The arterial first approach pancreaticoduodenectomy is safe and effective in the treatment of borderline resectable pancreatic cancer, which can improve the resection rate of SMA margin R0, and prolong patient survival time.
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Objective To analyze the effect of using standardized patient (SP) tutorial in the spe-cialized training of pancreatic surgery with WeChat platform. Methods 48 surgeons participating in resi-dent standardized training in Changhai Hospital (all for postgraduate education) were enrolled as teaching object. 48 surgeons were divided into two groups: SP group (n=24) receiving WeChat combined with SP tutorial which updates learning plan, learning contents, and clinical discussion by Wechat platform and performs practical teaching by SP method, control group (n=24) receiving traditional tutorial by using tradi-tional clinical teaching methods and video teaching followed by practical teaching. The theoretical exami-nation, questionnaires and expert assessment were used to evaluate the effect of the two teaching methods. Statistical analysis was performed using the SPSS 19.0. Continuous data were expressed as median±stan-dard deviation and compared using the Student's t-test. Categorical data were compared using the Pearson's chi-square test. Results The score of theoretical examination of the two groups showed no significant difference [(85.5±7.6) vs. (81.4±14.9), P=0.238]. The results of questionnaires and expert assessment in WeChat&SP group were significantly better than those in the control group (P0.05). Conclusion WeChat platform combined with standardized patient tutorial in the specialized training of pancreatic surgery is feasible and more effective than traditional tutorial to improve teaching effectiveness.
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To study and analyze the causes of chylous leakage after pancreaticoduodenectomy. We retrospectively analyzed 381 patients who underwent pancreaticoduodenectomy [including pylorus-preserving pancreaticoduodenectomy] in Shanghai Chang Hai Hospital Affiliated to the Second Military Medical University, Shanghai, China between January 2010 and December 2012. We also studied the relationship between postoperative chylous leakage and age, gender, surgical approach, and the tumor nature. The chylous leak was placed in 23 patients and the incidence of chylous leakage in patients was 0.6%. There was no significant difference in gender, age and tumor pathological pattern between the chylous leakage group and non-chylous leakage group. The incidence of chylous leakage in patients with N1 grade cancer was significantly higher than that in patients with N0 grade cancer [p=0.001]. The incidence of chylous leakage in patients suffering R0 resection was significantly higher than that in patients suffering non-R0 resection [p=0.008]. All patients were successfully treated conservatively. The incidence of chylous leakage was 0.6% and the chylous leakage was closely linked with the tumor's grade malignancy and the range of radical resection