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Objective:To investigate the clinical characteristics of choledocholithiasis com-bined with periampullary diverticulum and influencing factor for difficult cannulation of endoscopic retrograde cholangiopancreatography (ERCP).Methods:The retrospective case-control study was conducted. The clinical data of 1 920 patients who underwent ERCP for choledocholithiasis in 15 medical centers, including the First Hospital of Lanzhou University, et al, from July 2015 to December 2017 were collected. There were 915 males and 1 005 females, aged (63±16)years. Of 1 920 patients, there were 228 cases with periampullary diverticulum and 1 692 cases without periampullary diverticulum. Observation indicators: (1) clinical characteristics of patients with choledocholithiasis; (2) intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis; (3) influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. 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) or M( Q1, Q3), and com-parison between groups was conducted using the Wilcoxon rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. The Logistic regression model was used for univariate and multivariate analyses. Results:(1) Clinical characteristics of patients with choledocholithiasis. Age, body mass index, cases with complications as chronic obstructive pulmonary disease, diameter of common bile duct, cases with diameter of common bile duct as <8 mm, 8?12 mm, >12 mm, diameter of stone, cases with number of stones as single and multiple were (69±12)years, (23.3±3.0)kg/m 2, 16, (14±4)mm, 11, 95, 122, (12±4)mm, 89, 139 in patients with choledocholithiasis combined with periampullary diverticulum, versus (62±16)years, (23.8±2.8)kg/m 2, 67, (12±4)mm, 159, 892, 641, (10±4)mm, 817, 875 in patients with choledocholithiasis not combined with periampullary diver-ticulum, showing significant differences in the above indicators between the two groups ( t=?7.55, 2.45, χ2=4.54, t=?4.92, Z=4.66, t=?7.31, χ2=6.90, P<0.05). (2) Intraoperative and postoperative situations of patients undergoing ERCP for choledocholithiasis. The balloon expansion diameter, cases with intraoperative bleeding, cases with hemorrhage management of submucosal injection, hemostatic clip, spray hemostasis, electrocoagulation hemostasis and other treatment, cases with endoscopic plastic stent placement, cases with endoscopic nasal bile duct drainage, cases with mechanical lithotripsy, cases with stone complete clearing, cases with difficult cannulation, cases with delayed intubation, cases undergoing >5 times of cannulation attempts, cannulation time, X-ray exposure time, operation time were 10.0(range, 8.5?12.0)mm, 56, 6, 5, 43, 1, 1, 52, 177, 67, 201, 74, 38, 74, (7.4±3.1)minutes, (6±3)minutes, (46±19)minutes in patients with choledocholithiasis combined with periampullary diverticulum, versus 9.0(range, 8.0?11.0)mm, 243, 35, 14, 109, 73, 12, 230, 1 457, 167, 1 565, 395, 171, 395, (6.6±2.9)minutes, (6±5)minutes, (41±17)minutes in patients with choledocholithiasis not combined with periampullary diverticulum, showing significant differences in the above indicators between the two groups ( Z=6.31, χ2=15.90, 26.02, 13.61, 11.40, 71.51, 5.12, 9.04, 8.92, 9.04, t=?3.89, 2.67, ?3.61, P<0.05). (3) Influencing factor analysis for difficult cannulation in patients undergoing ERCP for choledocholithiasis. Results of multivariate analysis showed total bilirubin >30 umol/L, number of stones >1, combined with periampullary diverticulum were indepen-dent risk factors for difficult cannulation in patients with periampullary diverticulum who underwent ERCP for choledocholithiasis ( odds ratio=1.31, 1.48, 1.44, 95% confidence interval as 1.06?1.61, 1.20?1.84, 1.06?1.95, P<0.05). Results of further analysis showed that, of 1 920 patients undergoing ERCP for choledocholithiasis, the incidence of postoperative pancreatitis was 17.271%(81/469) and 8.132%(118/1 451) in the 469 cases with difficult cannulation and 1 451 cases without difficult cannula-tion, respectively, showing a significant difference between them ( χ2=31.86, P<0.05). In the 1 692 patients with choledocholithiasis not combined with periampullary diverticulum, the incidence of postopera-tive pancreatitis was 17.722%(70/395) and 8.250%(107/1 297) in 395 cases with difficult cannula-tion and 1 297 cases without difficult cannulation, respectively, showing a significant difference between them ( χ2=29.00, P<0.05). In the 228 patients with choledocholithiasis combined with peri-ampullary diverticulum, the incidence of postoperative pancreatitis was 14.865%(11/74) and 7.143%(11/154) in 74 cases with difficult cannulation and 154 cases without difficult cannulation, respectively, showing no significant difference between them ( χ2=3.42, P>0.05). Conclusions:Compared with patients with choledocholithiasis not combined with periampullary divertioulum, periampullary divertioulum often occurs in choledocholithiasis patients of elderly and low body mass index. The proportion of chronic obstructive pulmonary disease is high in choledocholithiasis patients with periampullary diverticulum, and the diameter of stone is large, the number of stone is more in these patients. Combined with periampullary diverticulum will increase the difficult of cannulation and the ratio of patient with mechanical lithotripsy, and reduce the ratio of patient with stone complete clearing without increasing postoperative complications of choledocholithiasis patients undergoing ERCP. Total bilirubin >30 μmol/L, number of stones >1, combined with periampullary diverticulum are independent risk factors for difficult cannulation in patients of periampullary diverticulum who underwent ERCP for choledocholithiasis.
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The diagnosis and treatment of complex biliary and pancreatic diseases is still one of the major problems and challenges faced by modern medicine. The concept of "precision surgery" proposed by academician Jiahong Dong provides a new way to solve this problem. With the rapid development of biliary and pancreatic endoscopy, it has become an important vehicle for the diagnosis and treatment of complex biliary and pancreatic diseases. In recent years, the authors have combined accurate endoscopy with precision surgery in the treatment of clinical complex biliary and pancreatic diseases, achieving good effects.
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Objective:To investigate the application value of digital single-operator peroral cholangioscopy on the preoperative evaluation of extrahepatic cholangiocarcinoma.Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 172 patients with extrahepatic cholangiocarcinoma who were admitted to the First Affiliated Hospital of Army Medical University from December 1, 2017 to April 1, 2022 were collected. There were 91 males and 81 females, aged 65(range, 45?68)years. Of 172 patients, 36 cases undergoing preoperative digital single-operator peroral cholangioscopy examination were allocated into the experimental group, and 136 cases not undergoing preoperative digital single-operator peroral cholangioscopy examination were allocated into the control group. Observation indicators: (1) propensity score matching and comparison of general data of patients between the two groups after matching; (2) surgical conditions. Propensity score matching was done by the 1:1 nearest neighbor matching method and caliper setting as 0.02. Measurement data with normal distribution were expressed as Mean± SD, and t test was used for comparison between groups. Measurement data with skewed distribution were expressed as M( Q1,Q3), and the Mann-Whitney U test was used for comparison between groups. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. The rank sum test was used for comparison of ordinal data. Results:(1) Propensity score matching and comparison of general data of patients between the two groups after matching. Of 172 patients, 60 cases were successfully matched, including 30 cases in the experiment group and 30 cases in the control group, respectively. Before propensity score matching, cases with or without preoperative bile drainage were 27, 9 in the experiment group, versus 62, 74 in the control group, showing a significant difference between the two groups ( χ2=9.86, P<0.05). The above indicators were 23, 7 in the experiment group, and 23, 7 in the control group after propensity score matching, showing no significant difference between the two groups ( χ2=0.00, P>0.05). The elimination of preoperative bile drainage confounding bias ensured comparability between the two groups. (2) Surgical conditions. After propensity score matching, there were 10 cases and 0 case without surgery in the two groups. Cases undergoing radical operation including R 0, R 1, R 2 resection were 16, 0, 4 in the experiment group, versus 18, 6, 6 in the control group, showing a significant difference between the two groups ( χ2=6.85, P<0.05). Conclusions:Preoperative digital single-operator peroral cholangioscopy exami-nation can improve the R 0 resection rate of extrahepatic cholangiocarcinoma.
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Benign biliary strictures (BBSs) is a kind of difficult clinical problem in biliary surgery. Surgery and endoscopic treatment are common diagnostic and therapeutic methods. The rapid development of endoscopic technology challenges the traditional surgery. How to integrate surgery and endoscopic technology in an orderly manner and develop strengths and circumvent weaknesses requires a breakthrough in guiding ideas. The precision surgery, with the characteristics of certainty, predictability, controllability, standardization, individualization and systematization, has become an ideal choice for integrating surgery and endoscopic technology. Based on clinical practice, the authors discuss the endoscopic diagnosis and treatment strategy of BBSs from the perspective of precision surgery by implementing the core elements of precision surgery.
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Objective:To explore the etiology, pathogenesis, clinical features, diagnosis and treatment of hepatic sinus obstruction syndrome(HSOS)after orthotopic liver transplantation(OLT).Methods:Clinical data were reviewed for 3 HSOS patients after OLT.Baseline profiles, primary disease, onset, clinical manifestations, abdominal imaging and pathological changes were recorded for summarizing the key points of diagnosis, treatment and outcomes of HSOS after OLT.Results:HSOS was an extremely rare complication after OLT with an incidence of 2%(2/117)and a median onset of 15(13-50)days.The major clinical manifestations were hepatic pain, abdominal distension, poor appetite, fatigue, jaundice, oliguria, peritoneal effusion and pleural effusion.Some of them were complicated with acute renal insufficiency.Abdominal ultrasonography revealed that blood stream of hepatic and portal veins was smooth but rather slow and hepatic parenchyma showed uneven echo changes.Abdominal enhanced computed tomography(CT)demonstrated " mosaic" and " map-like" uneven enhancement in portal vein and balance phases.The pathological manifestations of liver biopsy included obvious dilation and congestion of hepatic sinuses, swelling and necrosis of hepatic cells, thickening of hepatic venules and luminal stenosis or occlusion.All of them received immunosuppressants.Tacrolimus was switched to sirolimus, low molecular weight heparin or plus rivaroxaban anticoagulant thrombolytic therapy, methylprednisolone regulatory immunotherapy, albumin supplementation, diuresis, hepatic protection and fluid replacement.Afterward clinical symptoms of 2 patients improved, became cured and discharged.One case died from gastrointestinal hemorrhage and acute renal failure secondary to multiple organ failure.Conclusions:HSOS is an extremely rare but severe complication after OLT.Early diagnosis and fine-tuning of treatment protocols can avoid poor prognosis such as liver and kidney failure and significantly improve patient survival.
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Objective:To evaluate combining fistula risk score(FRS) with drain fluid amylase on postoperative day 1(DFA1) in predicting clinically relevant postoperative pancreatic fistula(CR-POPF) following pancreaticoduodenectomy(PD).Methods:The clinical data of 430 patients who underwent PD in the First Affiliated Hospital of Amy Medical University from Jan 2013 to Oct 2015 was retrospectively analyzed, receiver operating characteristic curve(ROC curve) was used to test whether the FRS predicts the CR-POPF, and DFA1 was employed to predict the CR-POPF in the moderate/high subgroup patients(FRS 3-10).Results:Fifty six patients(13.0%) had CR-POPF, the ROC curve for FRS predicting CR-POPF was formed with area under curve 0.894(95% CI: 0.861-0.921, P<0.001), the results from univariate and multivariate logistic regression analysis showed that FRS was independent risk factor associated with CR-POPF ( OR=2.933, 95% CI: 2.230-3.856, P<0.001). After dividing 430 patients into 2 groups by FRS category, there was no CR-POPF in negligible/low subgroup patients(FRS 0-2), and FRS>2 predicted CR-POPF with negative predictive value 100%; in moderate/high subgroup patients(FRS 3-10), ROC curve worked out DFA1>653.9 U/L predicting CR-POPF well with sensitivity, specificity, positive and negative predictive value of 87.5%, 63.8%, 39.2%, 95.0%, respectively. Conclusion:For patients with FRS≤2, and FRS≥3 accompanying DFA1≤650 U/L, early removal of intra-abdominal drains after PD is safe.
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Advanced intrahepatic cholangiocarcinoma(ICC) is one of the most common hepatic malignant tumors besides hepatocellular carcinoma, with occult onset, limited treatment and poor prognosis. Systemic treatment is a recommendable solution for advanced unresectable ICC. The authors reported the clinical experience of an ICC patient who underwent transarterial chemoembolization combined with immunotherapy plus target therapy.
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Objective:To investigate the clinical efficacy of ex vivo liver resection and autotransplantation (ELRA) for liver complex space-occupying lesions.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 50 patients with liver complex space-occupying lesions who underwent ELRA in the First Hospital Affiliated to Army Medical University between June 2009 and May 2017 were collected. There were 36 males and 14 females, aged from 13 to 69 years, with a median age of 51 years. All patients underwent ELRA. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up was conducted by outpatient examination or telephone interview. Patients were followed up according to the individual follow-up plan in the first 6 months after discharge, and then once every 3 to 6 months to detect tumor recurrence and survival up to May 2019. Measurement data with normal distribution were represented as Mean± SD. Measurement data with skewed distribution were represented as M (range). Count data were expressed as absolute numbers or percentages. The Kaplan-Meier method was used to calculate survival rates and draw survival curves, and Log-rank test was used for survival analysis. Results:(1) Surgical situations: all the 50 patients underwent ELRA successfully, and postoperative pathological examination showed the R 0 resection rate was 100%(50/50). The operation time of the 50 patients were (630±186)minutes, of which 9 patients with liver benign occupation had the operation time of (684±168)minutes and 41 patients with liver malignant tumor had the operation time of (618±190)minutes. The operation time of temporary reconstruction of inferior vena cava and portacaval shunt, time of anhepatic phase, volume of intraoperative blood loss of the 50 patients were (35±9)minutes, (256±71)minutes, 2 000 mL(range, 400-10 000 mL), respectively. The remnant liver mass to standard liver mass ratio of the 50 patients was 65%±16%, of which 9 patients with liver benign occupation had the remnant liver mass to standard liver mass ratio of 63%±14% and 41 patients with liver malignant tumor had the remnant liver mass to standard liver mass ratio of 65%±17%. Of the 50 patients, 35 had vascular invasion (7 cases with liver benign occupation, 28 cases with liver malignant tumor), of which 24 (6 cases with liver benign occupation, 18 cases with liver malignant tumor) underwent in vitro vascular reconstruction, 12 (5 cases with liver benign occupation, 7 cases with liver malignant tumor) had bile duct invasion and underwent choledochojejunostomy due to the inability of the common bile duct to anastomose the ends. Two cases with liver metastasis of gastric cancer, one case with liver metastasis of colon cancer and one case with liver metastasis of pancreatic cancer underwent radical gastrectomy, radical resection of colon cancer, and pancreaticoduodenectomy, respectively. (2) Postoperative situations: the duration of postoperative hospital stay of the 50 patients were 25 days (range, 11-169 days). Of the 50 patients, 12 had pleural effusion who were treated with pleural puncture drainage, 10 had bile leakage who were treated with abdominal puncture drainage, 3 had bile duct anastomotic leakage who were treated with endoscopic nasobiliary drainage or biliary stent implantation, 6 underwent reoperation among which 4 underwent exploratory laparotomy due to abdominal hemorrhage, 1 underwent portal vein reconstruction due to abdominal hemorrhage combined with portal vein thrombosis, and 1 underwent salvage liver transplantation due to liver failure. Nine of the 50 patients died within 90 days after surgery, all of whom had liver malignant tumor. Among them, 3 died of multi-organ dysfunction syndrome caused by severe infection, 3 died of acute liver failure, 2 died of abdominal hemorrhage and 1 died pulmonary embolism. (3) Follow-up: all the 50 patients were followed up for 1 to 119 months. The overall survival time, 1-, 3-, 5-year overall and tumor-free survival rates of the 50 patients after operation were 17 months (range, 1-119 months), 68.0%, 45.9%, 41.1% and 41.9%, 33.4%, 30.8%, respectively. The overall survival time, 1-, 3-, 5-year overall and tumor-free survival rates of the 9 patients who with liver benign occupation after operation were 68 months (range, 10-114 months), 88.9%, 88.9%, 88.9% and 88.9%, 88.9%, 88.9%, respectively. The overall survival time, 1-, 3-, 5-year overall and tumor-free survival rates of the 41 patients who with liver malignant tumor after operation were 15 months (range, 1-119 months), 63.4%, 36.6%, 31.0% and 31.5%, 21.0%, 18.0%, respectively. There were significant differences in the overall and tumor-free survival rates between patients who with liver benign occupation and patients who with liver malignant tumor ( χ2=7.626, 11.766, P<0.05). Conclusions:ELRA can be applied in the treatment of liver complex space-occupying lesions. The selection criteria of patients with liver malignant tumor should be more rigorous to reduce perioperative mortality.
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End-stage liver disease (ESLD) is a serious threat to human health, and liver transplantation is the only effective treatment. However, most of the patients died in the process of waiting for transplantation due to the shortage of liver source. With the rapid development of biological tissue enginee-ring technology, researchers have established the strategy of 'decellularized and recellularized technology’, which has deve-loped into the first choice for construction of important organs such as the liver and opened up new ideas for the treatment of ESLD. At present, scientists are working on the optimization of this technology, in order to construction a functional 'new liver’ for transplantation. The authors review the feasibility and challenges of the application of this technology and its optimization stra-tegy in the field of regenerative surgery.
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Objective:To investigate the application value of artificial neural network in laparoscopic surgery training.Methods:The prospective cohort study was conducted. A total of 158 trainees from the First Hospital Affiliated to Army Medical University between Semptember and November, 2019 who had no experience in laparoscopic technology were selected for laparoscopic surgery training, including 52 graduate students of surgery from grade 2019, 2018 and 2017, 58 surgeons receiving standardized residency training, 12 interns and 36 refresher physicians. The 158 trainees were divided into two groups using the random number table. Trainees trained by artificial neural network laparoscopic simulator were allocated into artificial neural network group, and trainees trained by box laparoscopic simulator were allocated into general laparoscopic simulator group. Trainees in both groups were trained using the laparoscopic simulator for 10 hours (5-day continuous training, 2 hours per day) on fundamentals of laparoscopic surgery. Observation indicators: (1) comparison of operation grades on laparoscopic simulator before and after training in the two groups; (2) comparison of improvement of the operation grades on laparoscopic simulator after training between the two groups. Measurement data with normal distribution were represented as Mean± SD, comparison within groups was analyzed using the paired t test and comparison between groups was analyzed using the independent sample t test. Measurement data with skewed distribution were represented as M (range). Results:A total of 158 trainees were selected for eligibility, including 140 males and 18 females, aged from 23 to 34 years, with a median age of 27 years. Of the 158 trainees, 79 were in the artificial neural network group and 79 were in the general laparoscopic simulator group. (1) Comparison of operation grades on laparoscopic simulator before and after training in the two groups: operation grades of the nails transferring, pattern cutting, ligation, sewing knots in vivo and sewing knots in vitro for the artificial neural network group before training were 51.2±4.9, 45.6±3.7, 43.0±3.6, 42.1±3.1, and 39.6±3.1, respectively. The above indicators for the artificial neural network group after training were 78.6±3.0, 76.4±3.9, 79.9±2.5, 78.3±3.5, and 84.1±3.8, respectively. There were significant differences in the above indicators for the artificial neural network group before and after training ( t=-42.490, -56.256, -80.373, -70.802, -79.742, P<0.05). The above indicators for the general laparoscopic simulator group before training were 50.1±2.9, 45.4±3.9, 42.7±3.0, 42.3±3.4, and 39.2±4.7, respectively. The above indicators for the general laparoscopic simulator group after training were 70.4±5.0, 69.8±4.0, 72.3±3.3, 72.3±3.5, and 72.8±3.2, respectively. There were significant differences in the above indicators for the general laparoscopic simulator group before and after training ( t=-28.942, -42.436, -58.357, -52.322, -53.098, P<0.05). (2) Comparison of improvement of the operation grades on laparoscopic simulator after training between the two groups: improvement of the operation grades in the nails transferring, pattern cutting, ligation, sewing knots in vivo and sewing knots in vitro for the artificial neural network group after training were 27.4±5.7, 30.8±5.0, 36.9±4.1, 36.2±4.5 and 39.5±5.4, respectively. The above indicators for the general laparoscopic simulator group after training were 20.3±6.2, 24.4±5.1, 29.6±4.5, 29.9±5.1 and 33.5±5.6, respectively. There were significant differences in the above indicators between the two groups ( t=7.597, 7.946, 10.638, 8.200, 6.969, P<0.05). Conclusion:The introduction of artificial neural network in laparoscopic surgery training can improve the training effects.
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Objective@#To explore the application effect of mixed reality technology in the teaching of hepatobiliary surgery.@*Methods@#A total of 120 professional postgraduates majored in surgery who had received the four-month standardized training of residents in hepatobiliary surgery department of the First Affiliated Hospital of Army Military Medical University and the First Affiliated Hospital of Chongqing Medical University during 2016-2018 were selected and were equally allocated into the control group and the research group via random number table method. Students in the control group were trained with traditional surgical teaching mode and in the research group were trained with three-dimensional visualization model which was constructed by mixed reality. Students in both groups received assessment and questionnaires at the end of training.@*Results@#Scores of theoretical examination and surgical operation assessment of students in the research group were higher than those in the control group (P<0.05). The error rate for separating gallbladder artery and bile duct in the laparoscopic simulated system of students in the research group was significantly lower than that in the control group (P<0.05). Students-teacher satisfaction degree in the research group was higher than that in the control group (P<0.05).@*Conclusion@#Using mixed reality technology to construct a three-dimensional visualization model and to implement hepatobiliary surgery teaching enables the trainees to better master anatomical key points in the hepatobiliary system and the hepatobiliary surgical approach, with good feedback.
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Objective To explore the application effect of mixed reality technology in the teaching of hepatobiliary surgery.Methods A total of 120 professional postgraduates majored in surgery who had received the four-month standardized training of residents in hepatobiliary surgery department of the First Affiliated Hospital of Army Military Medical University and the First Affiliated Hospital of Chongqing Medical University during 2016-2018 were selected and were equally allocated into the control group and the research group via random number table method.Students in the control group were trained with traditional surgical teaching mode and in the research group were trained with three-dimensional visualization model which was constructed by mixed reality.Students in both groups received assessment and questionnaires at the end of training.Results Scores of theoretical examination and surgical operation assessment of students in the research group were higher than those in the control group(P＜0.05).The error rate for separating gallbladder artery and bile duct in the laparoscopic simulated system of students in the research group was significantly lower than that in the control group(P＜0.05).Students-teacher satisfaction degree in the research group was higher than that in the control group(P＜0.05).Conclusion Using mixed reality technology to construct a three-dimensional visualization model and to implement hepatobiliary surgery teaching enables the trainees to better master anatomical key points in the hepatobiliary system and the hepatobiliary surgical approach,with good feedback.
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At present,liver transplantation has become an important therapy for patients with end-stage liver and gallbladder diseases.However,biliary stricture after liver transplantation occurs commonly and greatly,which hampers the clinical efficacy.Endoscopic retrograde cholangiopancreatography has become the first choice for diagnosis and treatment of biliary stricture after liver transplantation,though its operation is difficult and complicated.In recent years,a large number of studies on the pathogenesis and prevention of biliary stricture after liver transplantation have been investigated.Endoscopic diagnosis and treatment also have made great theoretical and technological advances.In this review the author aims to analyze the current literature and make a detailed discussion on the above issues,in order to provide reference for domestic counterparts.
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Objective@#To explore the risk factors of pancreatic fistula after pancreatoduodenectomy and its relationship with pancreatic fibrosis.@*Methods@#Retrospective analysis was made including 408 patients who underwent pancreaticoduodenectomy from January 2013 to December 2015 in Department of Hepatobiliary Surgery of the First Affiliated Hospital of Third Military Medical University. There were 274 males and females, aging from 14 to 82 years with an average age of 54.6 years. Postoperative pathological diagnosis: 285 cases with pancreatic ductal adenocarcinoma, 81 cases with gastrointestinal tumors, 13 cases with neuroendocrine tumors, 16 cases with inflammatory changes, 8 cases with pancreatic papillary tumors, 4 cases with serous cystadenoma, 1 case with retroperitoneal liposarcoma.Univariate analysis using pearson′s χ2 test, multivariate analysis using binary Logistic regression analysis, correlation analysis using Spearman rank correlation analysis and the predictive value of pancreatic fibrosis in pancreatic fistula after pancreaticoduodenectomy was assessed using the area under the receiver operating characteristic(ROC) curve.@*Results@#There were 123 cases (30.1%) with postoperative pancreatic fistula among 408 patients. Univariate analysis showed that body mass index(BMI)(P=0.005), preoperative gamma-glutamyltranspeptidase content(P=0.046), pancreatic duct diameter(P=0.001), CT value of pancreatic tissue(P=0.049), operation time(P=0.037), pancreatic stiffness (intraoperative judgment)(P=0.001) and percentage of pancreatic fibrosis(P=0.034) were the prognostic factors of pancreatic fistula. Multivariate analysis showed that BMI≥25 kg/m2, pancreatic duct diameter ≤3 mm, pancreatic tissue CT value <40 Hu, pancreatic hardness (intraoperative judgments) for the soft and pancreatic lobular fibrosis percentage ≤25% of postoperative pancreatic fistula occurrence of high-risk factor(P<0.05). Pancreatic fistula′s CT value and percentage of pancreatic fibrosis were significantly lower than non-pancreatic fistula group, the difference was statistically significant(P<0.05). There were significant differences in CT value and pancreatic lobular fibrosis among different grades of pancreatic fistulae(P<0.05). Pancreatic fistula severity was negatively correlated with the CT value of pancreatic body and the percentage of fibrosis of the pancreas(P=0.005, 0.019), and there was a significant correlation between CT value of pancreatic body and the percentage of fibrosis of the pancreas(r=0.699, P=0.028). The areas under the ROC curve of percentage of pancreatic fibrosis and CT value of the pancreatic body were 0.745 and 0.714, respectively. Both of them were moderate predictive value for pancreatic fistula after pancreaticoduodenectomy.@*Conclusions@#The degree of pancreatic fibrosis is a prognostic factor for pancreatic texture and pancreatic fistula after pancreaticoduodenectomy. CT value of pancreatic body can be used as a quantitative index of pancreatic fibrosis, and predict the prognostic of pancreatic fistula after pancreaticoduodenectomy.
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Objective To study the expression of connective tissue growth factor(CTGF) and PEST containing nuclear pro‐tein(PCNP) and their significance in pancreatic cancer .Methods The expressions of CTGF and PCNP proteins were tested by im‐munohistochemistry and Immunofluorescence in 39 cases of pancreatic carcinomas and adjacent paracancerous tissues .Results The positive rate of CTGF and PCNP in pancreatic carcinomas was significantly higher than adjacent paracancerous tissues(χ2 =60 .41 , 51 .46 ,all P<0 .01) .The differences of the expression of CTGF and PCNP in pancreatic carcinoma of tumor differentiation ,TNM stage and lymph node metastasis was significant (P< 0 .05) .Conclusion The expression of CTGF and PCNP in the pancreatic cancer was obviously increased ,and the level of CTGF ,PCNP had remarkable connection with the stages of tumor and the condition of lymph node metastasis .
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Objective To investigate the clinical application value of pancreatoduodenectomy combined with vascular resection and reconstruction for pancreatic head carcinoma.Methods The clinical data of a patient with pancreatic head carcinoma who underwent pancreatoduodenectomy combined with vascular resection and reconstruction at the Southwest Hospital in March 2014 were retrospectively analyzed.Preoperative imaging examination showed no gap between vascular wall of portal vein (PV) and pancreatic head space-occupying lesion,vascular compression and stenosis at intersection of PV,splenic vein (SV) and superior mesenteric vein (SMV),but not excluding adjacent main PV invasion.During the operation,it was difficult to separate pancreatic head carcinoma from PV,indicating vascular wall invasion at intersection of PV,SV and SMV.Therefore,the pancreatic head,bile ducts,duodenum,partial jejunum,invasive vein vessels,lymphatic and nerve tissues were radically resected,then PV,SMV and SV were reconstructed.The patient was followed up by outpatient examination and telephone interview after surgery till April 2015.Results The patient underwent pancreatoduodenectomy combined with vascular resection and reconstruction successfully without blood transfusion.The operation time was 285 minutes and volume of intraoperative blood loss was 300 mL.The patient had a smooth postoperative recovery,resuming diet at postoperative day 5.The abdominal drainage tube and stitches were removed at postoperative day 6 and day 12,and the patient was discharged from hospital at postoperative day 15.Computed tomography reexamination showed clear vascular anastomose.The patient was not complicated with pancreatic fistula,biliary fistula,intra-abdominal hemorrhage and vascular embolism.The postoperative pathological examination confirmed the diagnosis of pancreatic head moderately differentiated adenocarcinoma accompanied by PV invasion and lymph node metastasis,with a negative margin.The patient began a course of single drug common chemotherapy using gemcitabine at postoperative day 40.No cancer recurrence was detected during the one-year follow-up.Conclusion Pancreatoduodenectomy combined with vascular resection and reconstruction is safe and feasible for the treatment of pancreatic head carcinoma with good surgical effects.
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Objective To investigate the significance of combined vascular resection and reconstruction in surgery for pancreatic cancer.Methods The clinical data of 231 patients with pancreatic canccr who received pancreaticoduodenectomy at the Southwest Hospital from January 2006 to December 2011 were retrospectively analyzed.All the patients were divided into the combined vascular resection and reconstruction group (97patients) and non-vascular resection and reconstruction group (134 patients).Effects of operation,results of pathological examination,prognosis and lymph node metastasis on the prognosis of the patients in the 2 groups were compared.Two independent samples t test was used to analyze the measurement data,and the count data were analyzed using the chi-square test.The survival curve was drawn by the Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Results The operation time and intraoperative volume of blood loss were (554 ± 136)minutes and (1110 ± 939)rnl in the combined vascular resection and reconstruction group,and (445 ±106)minutes and (623 ±349)ml in the non-vascular resection and reconstruction group,with significant difference between the 2 groups (t =6.552,4.873,P ＜ 0.05).The mortality,morbidity and positive rate of lymph node metastasis of were 8.2％ (8/97),20.6％ (20/97) and 32.0％ (31/97) in the combined vascular resection and reconstruction group and 3.0％ (4/134),8.2％ (11 / 134) and 16.4％ (22/134) in the non-vascular resection and reconstruction group.There was no significant difference in the mortality between the 2 groups (x2=3.164,P ＞ 0.05),while significant differences in the morbidity and positive rate of lymph node metastasis were detected between the 2 groups (x2 =7.458,7.687,P ＜ 0.05).A total of 223 patients were followed up till September 2012,53 patients were with lymph node metastasis,and their median survival time was 8.4 months (range,6.9-10.0 months) ; 170 patients were with negative lymph node metastasis,and their median survival time was 18.6 months (range,15.8-21.5 months),which was significantly longer than that of patients with positive lymph node metastasis (x2=17.045,P ＜ 0.05).Of the 53 patients with lymph node metastasis,31 were in the combined vascular resection and reconstruction group,and their median survival time was 8.5 months (range,6.3-10.7 months) ; 22 were in the non-vascular resection and reconstruction group,and their median survival time was 8.3 months (range,6.1-10.5 months),with no significant difference between the 2 groups (x2 =0.022,P ＞ 0.05).Of the 178 patients with negative lymph node metastasis,64 were in the combined vascular resection and reconstruction group,and their median survival time was 13.2 months (range,9.2-17.1 months) ; 106 were in the non-vascular resection and reconstruction group,and their median survival time was 21.7 months (range,18.1-25.3 months),with significant difference between the 2 groups (x2 =11.908,P ＜ 0.05).Conclusions Although pancreaticoduodenectomy combined with vascular resection and reconstruction increases the incidence of postoperative complications,it could achieve the complete removal of tumors without significantly increasing the mortality rate.For patients with lymph node metastasis,pancreaticoduodenectomy combined with vascular resection and reconstruction has no influence on the postoperative survival time,while it might have influence on the patients without lymph node metastasis.
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Objective To investigate the molecular mechanism of epithelial-mesenchymal transition (EMT) induced by activated vascular endothelial growth factor receptor-1 ( VEGFR-I ) in cell line MHCC97-H.Methods MHCC97-H cells were cultured in DMEM with 1％ fetal bovine serum (control group),10 μmol/L PP2 (PP2 group),10 μmol/L PBS (PBS group),50 μmol/L VEGF-B (VEGF-B group),l0μmol/L PP2 and 50 μmol/L VEGF-B (PP2 +VEGF group),10 μmol/L PBS and 50 μmol/L VEGF-B (PBS + VEGF-B group),respectively.Protein expressions of epithelial marker E-cadherin,α-catenin and mesenchymal marker vimentin and N-cadherin were detected by Western blot.The expression sites of E-cadherin,α-catenin and mesenchymal marker vimentin and N-cadherin were detected by cell immunofluorescence.The ability of invasion and migration of cell line MHCC97-H were assessed by cell invasion and migration test.All data were analyzed by the t test.Results The expressions of E-cadherin,α-catenin,vimentin and N-cadherin were 3.23 +0.76,3.01 ±0.25,3.01 +0.22 and 2.63 +0.40 in the control group,4.18 +0.32,3.29 +0.11,4.85 +0.36 and 3.02 +0.52 in the PP2 group,2.83 +0.65,3.03 +0.27,1.37 ±0.24 and 2.98 ±0.36 in the PBS group,2.06 ±0.15,2.84 ±0.76,5.79 ± 0.38 and 5.54 ± 0.28 in the VEGF-B group,6.12 ± 0.08,5.45 ± 0.37,3.36 ± 0.42 and 3.26 ±0.13 in the PP2 + VEGF-B group and 1.36 ±0.54,1.26 ±0.45,4.05 ±0.17 and 1.05 ±0.33 in the PBS +VEGF-B group.There was a significant difference in the expressions of E-cadherin and α-catenin between the PP2 +VEGF-B group and the VEGF-B group (t =7.625,9.931,P ＜ 0.05 ).The expressions of vimentin and N-cadherin in the PP2 + VEGF-B group were significantly lower than those in the VEGF-B group (t =12.001,11.910,P ＜ 0.05).Six hours after the treatment with VEGF-B,the numbers of MHCC97-H migrated were 19 ± 1,5 ± 2and 16 ± 1 in the VEGF-B group,PP2 + VEGF-B group and PBS + VEGF-B group,respectively.The number of MHCC97-H cells migrated in the VEGF-B group was greater than that in the PP2 ± VEGF-B group ( t =13.566,P ＜ 0.05 ).The number of MHCC97-H cells passed through the Boyden chamber was 4 + 2,which was significantly less than 16 ± 1 of the VEGF-B group (t =12.350,P ＜0.05).Conclusion EMT induced by activated VEGFR-1 was mediated via c-Src kinase signal transduction in MHCC91-H cell line,and c-Src may be a potential target to interfere the invasion and migration of hepatic cancer cells.
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Objective To investigate the efficacy of pancreaticoduodenectomy (PD) combined with vascular resection and reconstruction.Methods The clinical data of 56 patients who received PD combined with vascular resection and reconstruction at the Southwest Hospital of Third Military Medical University from January 2007 to May 2011 were retrospectively analyzed.The incidence of perioperative complications,mortality and postoperative conditions were also analyzed.Results The mean operation time and intraoperative blood transfusion were 473 minutes (range,234-853 minutes) and 781 ml (range,0-900 ml),respectively.Seven patients did not receive blood transfusion.The median period of hospital stay was 25.9 days (range,17-100 days).A total of 43 patients underwent PD combined with vascular reconstruction.The incidence of perioperative complications and mortality rate were 34％ (19/56) and 7％ (4/56),respectively.There were 42 patients with pancreatic ductal adenocarcinoma,5 with ampullary carcinoma,3 with distal bile duct carcinoma,4 with papillary carcinoma of duodenum,1 with pancreatic neuroendocrine carcinoma and 1 with pancreatic serous cystadenoma.All patients were followed up till August 2011,and the 1-year survival rate was 57％ (32/56).The mean survival time was 13.5 months.The weight of 32 surviving patients increased and no abdominal pain occurred.Within 3 months after the operation,5 patients had slight diarrhea and were administered antidiarrheal; thrombosis in the artificial blood vessels and peritoneal effusion were found in 1 patient,while 6 months later,collateral circulation was formed and the peritoneal effusion was diminished.Conclusion PD combined with vascular resection and reconstruction can improve the quality of life for patients with pancreatic cancer and with blood vessels involvement.
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Objective To investigate the diagnosis and treatment of functional pancreatic endocrine tumors (PETs). Methods The clinical data of 45 patients with functional PETs who were admitted to the Southwest Hospital from January 1998 to December 2008 were retrospectively analyzed. Etiologic and localization diagnosis were made preoperatively according to the manifestation and the results of color doppler ultrasound and computed tomography, respectively. Eight patients received resection of the body and tail of the pancreas and spleen, 32 received tumor enucleation, one received resection of the pancreaticobiliary junction and four received pancreaticoduodenectomy. All patients received chemotherapy after the operation. Results Thirty-four cases of the PETs were benign and the rest eleven cases were malignant. Eight cases of the PETs were in the head of the pancreas,26 in the tail of the pancreas, seven in the body of the pancreas and four cases were with multiple PETs. The diameters of the PETs were 0. 3-5.0 cm, and the diameters of the PETs in 19 cases were above 2.0 cm. Eight patients were complicated with pancreatic leakage, two with incision infection and one with abdominal infection. Of the 33 patients with insulinoma, the blood glucose of five patients with multiple PETs was still abnormal after the operation, three patients underwent reoperation and the other two were treated by diazoxide to control the blood glucose in the normal range. The clinical symptoms of the seven patients with gastrinoma disappeared after the operation, and the gastric ulcer was healed, the 12-hour gastric juice volume and the level of the gastric acid were in the normal range after a continuous treatment with proton pump inhibition agents for 6 months. Necrotizing or migratory rash and diabetes of the four patients with glucagonoma were cured three weeks later, and the level of the amino acid was back to normal. Diarrhea and electronic disturbance of one patient with vasoactive intestinal peptide tumor were alleviated after the operation. Thirty-nine patients were followed up for 20-120 months. Of the 32 patients with benign PETs, two patients had tumor recurrence, and three patients died of other diseases. Of the seven patients with malignant PETs, two patients survived, and three patients died of hepatic metastasis or tumor recurrence, two patients died of other diseases. Conclusions Surgical treatment is effective for the treatment of functional PETs. Palliative resection of the tumor also can obviously improve the life quality of patients with fuctional PETs.