Surgical intervention of acute necrotizing pancreatitis: timing is more important than technology / 中华消化外科杂志

At present, around the surgical and non-surgical treatment of acute necrotic pancreatitis, early surgery or late surgery, minimally invasive intervention or open surgery, consensus is gradually formed. Further exploring the optimal surgical timing and surgical techniques for the debridement, combination of the surgical and minimally invasive intervention strategies, and improving the success rate of delayed one-time surgical intervention is the key to further reduce the mortality rate of acute necrotic pancreatitis of the late stage. In the past two decades, the treatment mode of the late stage of acute necrotic pancreatitis had been changed extremely as the understanding of the pathology of local complications of acute necrosis pancreatitis has been deepened. From the early open surgery for abdominal decompression in the late 20th century to the planned multiple surgical debridement, and then to the postponement one-time surgery, as well as the development of step-up approach procedures in recent years, changement in the concept of treatment gradually achieved a breakthrough in efficacy. Compared with the techniques of different procedures for necrotic tissues, the choice of surgical timing is more important to the success of treatment. From the evidence-based results of existing studies of acute necrotic pancreatitis, it is not possible to determine the advantages of surgical techniques to improve the prognosis due to the complexity of acute necrotic pancreatitis, individual differences and limited results from multicenter research. The proper timing of surgery is indisputable in the role of improving the surgical effect of acute necrosis pancreatitis. The author reviews the clinical data of more than 1, 000 patients treated by the analytical team for the treatment of acute necrotic pancreatitis, and discusses the timing of surgical intervention and the clinical significance of technology for improving prognosis for the late stage of acute necrotic pancreatitis.

History and present status of treatment of acute necrotizing pacreatitis: a breakthrough in the past two decades / 中华外科杂志

For more than one hundred years, the surgery and non-surgery around acute necrosis pancreatitis, early and late stage-operative surgery have been strive explored, and every change in treatment concept, technological progress and breakthrough in efficacy have been gradually summarized and improved in practice.Clinical practice and basic research gradually clarified the understanding of the pathological physiological process of acute necrosis pancreatitis "two peaks of death", greatly improved the treatment of early organ failure, deepened the understanding of the diversity of pathological of local complications of acute necrosis pancreatitis, and changed the treatment mode of necrosis pancreatitis. A modern comprehensive treatment system has been gradually formed. That is, in the early stage of the disease, to prevent and control multi-organ failure as the main axis; In the later stage, to explore the best surgical intervention time as the main axis, the implementation of micro-invasive and open combination of intervention strategy, and strive to explore and improve the success rate of one-time surgery. At present, China′s treatment level of acute necrosis pancreatitis in many large-capacity centers is in the forefront of the world. Through the Pancreatic Surgery Group of Surgery Society of Chinese Medical Association′s tour of the Guide and a large number of academic exchanges, the level of treatment of necrosis pancreatitis in China′s primary hospitals is also constantly improving. Therefore, we have reasons to believe that the day when China′s acute necrotizing pancreatitis diagnosis and treatment level can break further will not be far away.

Clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy for infected pancreatic necrosis / 中华消化外科杂志

Objective@#To investigate the clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy (MARPN) for infected pancreatic necrosis (IPN).@*Methods@#The retrospective cohort study was conducted. The clinical data of 61 patients with IPN who were admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 2014 and December 2017 were collected. There were 39 males and 22 females, aged 36-67 years, with a median age of 49 years. Of 61 patients, 40 undergoing open surgery were allocated into open group, and 21 undergoing MARPN were allocated into MARPN group. All the patients underwent surgical treatments after standard non-surgical treatments according to the Guidelines for the diagnosis and treatment of severe acute pancreatitis (2014 edition). Observation indicators: (1) intraoperative and postoperative situations; (2) follow-up. Follow-up using telephone interview or outpatient examination was performed to detect weight loss, pathoglycemia, steatorrhea, intestinal obstruction, and pancreatic portal hypertension for one year after surgery up to December 2017. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Count data were represented as absolute numbers or percentages, and comparison between groups was done using the chi-square test.@*Results@#(1) Intraoperative and postoperative situations: operation time, time to out-of-bed activity, time to initial food intake, cases with reoperation, cases with postoperative multiple organ dysfunction syndrome (MODS), incidence rate of postoperative complications, mortality, time to drainage-tube removal, duration of hospital stay, and hospital expenses were (77±20)minutes, (13.0±3.6)days, (9.0±2.7)days, 8, 9, 45.0%(18/40), 7.5%(3/40), (37.0±6.3)days, (49±8)days, (84 321±8 872)yuan in the open group, and (59±20)minutes, (2.7±0.9)days, (1.9±0.4)days, 6, 2, 19.0%(4/21), 0, (21.0±2.7)days, (39±6)days, (58 594±3 576)yuan in the MARPN group, respectively, showing no significant difference in the cases with reoperation (χ2=0.69, P>0.05) but significant differences in the other indices between the two groups (t=4.24, 9.61, 15.34, χ2=23.76, 4.02, 36.03, t=11.07, 5.93, 8.43, P<0.05). There were 18 patients with postoperative complications in the open group, including 2 with digestive hemorrhage, 3 with abdominal hemorrhage, 9 with pancreatic leakage, and 4 with intestinal leakage. There were 4 patients with postoperative complications in the MARPN group, including 3 with pancreatic leakage, and 1 with intestinal leakage. Patients with complications were treated by endoscopy, interventional therapy, placement of jejunal nutrition tube, and ileum stoma. Three patients in the open group died, and all the patients in the MARPN group were cured. (2) Follow-up: 47 of 61 patients were followed up for one year, including 31 in the open group and 16 in the MARPN group. During the follow-up, weight loss, pathoglycemia, steatorrhea, intestinal obstruction, and pancreatic portal hypertension were detected in 4, 11, 5, 4, 5 patients of the open group and in 2, 6, 2, 0, 3 patients of the MARPN group, showing no statistically significant difference between the two groups (χ2=0.18, 0.02, 0.01, 0.03, 0.90, P>0.05).@*Conclusion@#MARPN for IPN is safe and reliable, with certain efficacy, which can effectively reduce incidence of postoperative complication, motality and shorten hospital stay.

Changes of surgical interventions on necrotizing pancreatitis / 中华外科杂志

Objective@#To investigate the changes of surgical invitations on necrotizing pancreatitis in recent 14 years by reviewing single center data.@*Methods@#One thousand and eighty patients with necrotizing pancreatitis who received surgical invitation were involved in the study.All the patients were treated at Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2005 to December 2018. Six hundred and seventy-eight were males and 402 were females. The median (range) age of the study patients was 45 (20-76) years.The etiology of the disease was related to cholelithiasis in 335 cases(31.02%), hyperlipemia in 302 cases(27.96%), alcohol in 226 cases(20.93%), endoscopic retrograde cholangiopancreatography in 28 cases(2.59%), pregnancy in 50 cases(4.63%), idiopathic factors in 72 cases(6.67%) and other causes in 67 cases(6.20%). The patients were divided into two groups according to the time of admission. Group 1 included 1 475 patients that admitted from January 2005 to December 2010, and group 2 included 1 539 patients that admitted from January 2011 to December 2018. The surgical interventions, morbidity and mortality of the two group were compared, and χ2 test was used for the statistical test.@*Results@#Two hundred and sixty-six among the 1 080 cases were treated with drainage procedures because of the pseudocyst.One hundred and seventy-five drainage procedures were performed between January 2005 and December 2018, which account for 11.87%(175/1 475) of all patients of necrotizing pancreatitis; 91 drainage procedures were performed between January 2011 and December 2018, which account for 5.91%(91/1 539) of all patients of necrotizing pancreatitis. Eight hundred and fourteen cases received surgical intervention for infection of necrotizing tissues. Of these cases, 410 cases received percutaneous catheter drainage(PCD) of retroperitoneal fluid or residual infection. Debridement of necrotic tissues was performed on 756 cases. Of these cases, 32 cases received minimal invasive retroperitoneal debridement with/without denotes video assistant, 4 cases received transluminal endoscopic debridement, 21 cases received laparoscopic debridement, and 709 cases received open laparotic debridement.Three hundred and sixty-five cases were admitted to our institute during January 2005 to December 2010, and the other 391 cases were admitted to our institute from January 2011 to December 2018. Of the first period, all debridement were performed with open laparotic procedures. Of the second period, debridement were performed with open laparotic procedures and minimal invasive procedures. The average times of surgical invasion, morbidity of principal local complications and mortality of the two periods were 1.27 and 1.34,28.22%(103/365) and 29.92%(117/346), and 6.03%(23/365) and 6.91%(27/346), respectively.@*Conclusions@#Minimal invasive procedures can be considered for debridement in patients with necrotizing pancreatitis in some selected conditions.The involvements of minimal invasive procedures in treatment of necrotizing pancreatitis don′t decrease the morbidity of principal local complications and mortality in recent years. Rational surgical procedures and appropriate surgical timing are the keys to improve the efficacy of necrotizing pancreatitis.

Rediscussion of the individualized surgical intervention and timing for necrotizing pancreatitis / 中华外科杂志

Necrotizing pancreatitis is a complicated disease with multiple clinical outcomes. Although it's hard to select appropriate treatment strategies, it's still an important branch in improving the curative effect. The pathology and outcome of local complications of necrotizing pancreatitis show great diversity and individualized differences in different patients and stages of pathogenesis. Currently, a variety of treatment strategies for local complications of necrotizing pancreatitis, including minimally invasive treatment and laparotomy, can be selected. Removal of infected and necrotic tissues and adequate drainage of peripancreatic effusion are the basic principles. In clinical practice, minimally invasive and laparotomy strategies should be dialectically implemented according to the specific conditions and indications of patients. And we should avoid unilaterally emphasizing one method over the other or invariably using one method to deal with all patients' conditions. Clinical practice has proved that the choice of operation time is more decisive than the selection of debridement method to the success of treatment for local complications of necrotizing pancreatitis. As long as the operation time is appropriate, any debridement method can achieve good results. Therefore, we should avoid the overemphasis on debridement method, and ignore the significance of operation time for patients. In clinical practice, we are supposed to attach importance to the timing of intervention and selection of intervention methods according to the specific conditions of patients.

Clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy for infected pancreatic necrosis / 中华消化外科杂志

Objective To investigate the clinical efficacy of minimal access retroperitoneal pancreatic necrosectomy (MARPN) for infected pancreatic necrosis (IPN).Methods The retrospective cohort study was conducted.The clinical data of 61 patients with IPN who were admitted to Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 2014 and December 2017 were collected.There were 39 males and 22 females,aged 36-67 years,with a median age of 49 years.Of 61 patients,40 undergoing open surgery were allocated into open group,and 21 undergoing MARPN were allocated into MARPN group.All the patients underwent surgical treatments after standard non-surgical treatments according to the Guidelines for the diagnosis and treatment of severe acute pancreatitis (2014 edition).Observation indicators:(1) intraoperative and postoperative situations;(2) follow-up.Follow-up using telephone interview or outpatient examination was performed to detect weight loss,pathoglycemia,steatorrhea,intestinal obstruction,and pancreatic portal hypertension for one year after surgery up to December 2017.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were represented as absolute numbers or percentages,and comparison between groups was done using the chi-square test.Results (1) Intraoperative and postoperative situations:operation time,time to out-of-bed activity,time to initial food intake,cases with reoperation,cases with postoperative multiple organ dysfunction syndrome (MODS),incidence rate of postoperative complications,mortality,time to drainage-tube removal,duration of hospital stay,and hospital expenses were (77±20)minutes,(13.0±3.6) days,(9.0±2.7)days,8,9,45.0％ (18/40),7.5％(3/40),(37.0±6.3)days,(49±8)days,(84 321±8 872)yuan in the open group,and (59± 20) minutes,(2.7±0.9) days,(1.9 ± 0.4) days,6,2,19.0％ (4/21),0,(21.0± 2.7) days,(39 ± 6) days,(58 594±3 576) yuan in the MARPN group,respectively,showing no significant difference in the cases with reoperation (x2=0.69,P＞0.05) but significant differences in the other indices between the two groups (t =4.24,9.61,15.34,x2=23.76,4.02,36.03,t=11.07,5.93,8.43,P＜0.05).There were 18 patients with postoperative complications in the open group,including 2 with digestive hemorrhage,3 with abdominal hemorrhage,9 with pancreatic leakage,and 4 with intestinal leakage.There were 4 patients with postoperative complications in the MARPN group,including 3 with pancreatic leakage,and 1 with intestinal leakage.Patients with complications were treated by endoscopy,interventional therapy,placement of jejunal nutrition tube,and ileum stoma.Three patients in the open group died,and all the patients in the MARPN group were cured.(2) Follow-up:47 of 61 patients were followed up for one year,including 31 in the open group and 16 in the MARPN group.During the follow-up,weight loss,pathoglycemia,steatorrhea,intestinal obstruction,and pancreatic portal hypertension were detected in 4,11,5,4,5 patients of the open group and in 2,6,2,0,3 patients of the MARPN group,showing no statistically significant difference between the two groups (x2=0.18,0.02,0.01,0.03,0.90,P＞0.05).Conclusion MARPN for IPN is safe and reliable,with certain efficacy,which can effectively reduce incidence of postoperative complication,motality and shorten hospital stay.

CT quantitative assessment between pancreatectomy volume and blood glucose level / 中华放射学杂志

Objective To evaluate the relationship between postoperative residual pancreatic volume and change of blood glucose levels. Method Eighty?five cases of pancreatic benign and malignant tumor patients with preoperative and postoperative pancreatic CT images and clinical data were included retrospectively. Preoperative and postoperative pancreatic volume in benign patients and malignant patients were measured. Eight five patients were divided into 5 groups according to the resection volume ratio. Blood glucose levels were compared at different resection volume ratios. Correlation analysis of pancreatic resection volume ratio and blood glucose level were conducted in 39 benign patients and 46 malignant patients.ANOVA test, t test and Peason correlation coefficient were used. Result Postoperative benign and malignant group glucose level difference had statistical significance (P<0.05). Preoperative and postoperative malignant group of glucose level difference had statistical significance (P<0.05). Benign postoperative blood glucose between each groups was statistically significant (P<0.05); Malignant postoperative blood glucose between each groups was statistically significant (P<0.05); The volume ratio of benign and malignant tumor resection was positively correlated with postoperative blood glucose level (r values were 0.85 and 0.77, P<0.01). Conclusions There were statistically significant differences in blood glucose levels between pre?operation and post?operation of benign and malignant tumors. Postoperative blood glucose level was correlated with pancreatic resection volume, and postoperative blood glucose level was positively correlated with resection volume ratio.

Selection strategy of neoadjuvant therapy for pancreatic cancer / 中华消化外科杂志

Pancreatic cancer is a common malignancy with the worst prognosis.Radical surgery has been the only curative treatment for pancreatic cancer.With the advancement of surgical techniques and the implementation of the concept of comprehensive treatment for cancer in recent years,neoadjuvant therapy for pancreatic cancer has received more attention.There are continuing controversies in the hotspots and difficulties,with opportunities and challenges coexisting.Four famous experts and their teams in pancreatic surgery discussed selection strategy of neoadjuvant therapy for pancreatic cancer based on clinical experiences.Professor Wang Chunyou proposed that surgery was prior for patients with a higher likelihood of achieving R0 resection for pancreatic cancer to avoid the possibility of tumor progression and loss the opportanity of radical resection during neoadjuvant therapy.For patients with less chance of radical resection for pancreatic cancer and unresectable pancreatic cancer,neoadjuvant therapy is worthy of a positive attempt.Professor Jin Gang and his team believed that neoadjuvant therapy played an important role in improving the survival time of patients with pancreatic head cancer,especially with borderline resectable pancreatic head cancer.After neoadjuvant therapy,pancreatic surgeons should pay attention to improvement of surgery safety and R0 resection rate.Professor Dai Menghua and his team suggested that patients with resectable pancreatic cancer and borderline resectable pancreatic cancer could benefit from neoadjuvant therapy,which required proof from clinical trials.Surgeons should choose the appropriate treatment strategy based on guidelines and individual conditions for patients with pancreatic cancer.Professor Shao Cheghao and his team suggested that surgical treatment after neoadjuvant therapy or translational therapy for locally advanced pancreatic head cancer is safe,effective and feasible,especially for pancreaticoduodenectomy with combined revascularization.For the treatment of patients with pancreatic head cancer after neoadjuvant chemotherapy,the choice of next treatment options,evaluation indicators,timing of surgery and surgical methods need to be further studied.

History of surgical intervention in severe acute pancreatitis treatment / 中华外科杂志

Severe acute pancreatitis (SAP) is hard to treat for the abrupt onset, critical condition and complicated pathophysiology. Historically, the treatment strategy of SAP hovered between surgical intervention and conservative treatment. At the turn of the 20(th) century, SAP was reported to be cured by surgical intervention in a series cases, which lead to the dominance of surgical intervention in SAP treatment. Subsequently, SAP was documented to respond to nonoperative therapy. A wave of conservatism emerged, and surgical intervention for SAP was rarely practiced for the next 3 decades. However, surgeons refined the indications and considered new approaches for surgical treatment in 1960s because of the poor outcomes of conservation, and surgical interventions was mainly performed at early stage of SAP. However, a series of prospective studies showed that conservative treatment of patients with sterile pancreatic necrosis is superior to surgical intervention, and that delayed intervention provide improved outcomes in 1990s, which changed the treatment concept of SAP again. The modern treatment concept formed during the progression: organ supportive care dominates in the early stage of the disease, and surgical intervention should be performed at late stage with proper indications. Despite the advances in treatment, the morbidity of SAP is still 5%-20%, which suggests the pancreatic surgeons' exploration in the future.

Surgical treatment of necrotizing pancreatitis: 10-year experience at a single center / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the indication, timing and methods of surgery for acute necrotizing pancreatitis.</p><p><b>METHODS</b>There were 5 538 patients with acute pancreatitis (AP) were treated in the Union Hospital, Tongji Medical College from January 2005 to December 2014. Of all AP cases, 2 415 patients with acute necrotizing pancreatitis proved by computed tomography, and 732 patients underwent surgical treatment. Among 732 patients with surgical treatment, 439 (60.0%) were males and two hundreds and ninety-three (40.0%) were females. The median age was 45 years, ranging 20-76 years. Two hundreds and eighty-nine cases were treated with minimally invasive debridement and drainage and 684 cases were treated with open debridement.</p><p><b>RESULTS</b>The cure rate of minimally invasive operation was 16.6% (48/289). The rest of the 241 patients were treated furtherly with open necrosectomy. Among 684 patients with open surgery, 523 patients (76.5%) were infected, and the median time from the onset of symptom to first open operation was 46 d (range 19-205 d). There were 115 patients need to surgery again because of necrotic tissue residual and the reoperation rate was 16.81% (115/684), 684 patients were performed open surgery on average 1.26 times per person. The main postoperative complications were intra-abdominal hemorrhage (37 cases), upper digestive tract fistula (34 cases), colonic fistula (12 cases), gastrointestinal obstruction (29 cases) and pancreatic fistula (83 cases). The overall incidence of complications were 28.5% (195/684). Forty-nine cases died after surgery and the mortality rate was 6.7% (49/732).</p><p><b>CONCLUSION</b>Rational surgical indications and timing of surgical intervention are the key to improve the efficacy of necrotizing pancreatitis, open debridement is still an effective method for necrotizing pancreatitis.</p>

Understanding of the Guidelines for the Diagnosis and Treatment of Acute Pancreatitis (2014 edition): Hot issues of surgical treatment of acute pancreatitis / 中华消化外科杂志

Presently,tremendous progress has been achieved in the research of acute pancreatitis (AP),which lead to significant changes in many important aspects of the diagnosis and treatment for AP.In 2014,the Pancreatic Surgery Group of Surgery Branch of Chinese Medical Association revised the Guidelines for the Diagnosis and Treatment of Severe Acute Pancreatitis which was published in 2007.In the revised guidelines,the severity of AP is classified as mild acute pancreatitis (MAP),moderately severe acutepancreatitis (MSAP) and severe acute pancreatitis (SAP).The definition of SAP or MSAP depends on the duration of organ failure,which is persistent (＞48 hours) in SAP but is transient (≤48 hours) in MSAP.Modified CT severity index (MCTSI) is used as the imaging evaluation.Acute peripancreatic fluid collection (APFC),acute necrotic collection (ANC),walled-off necrosis (WON) and pancreatic pseudocyst are the local complications.The disease course is divided into 3 stages,including early stage (acute phase),middle stage (evolution phase) and late stage (infection phase).Infected necrosis is an indication for the surgical treatment,but the surgery should not be performed in sterile necrosis.Meanwhile,surgical treatment should follow the delayed principle.Surgical methods that include percutaneous drainage (PCD),minimally invasive surgery and open surgery could be selected separately orjointly.

Low microRNA-217 expression in colorectal cancer tissues predicts poor prognosis in colorectal cancer patients / 中华普通外科杂志

Objective To investigate microRNA-217 expression and its significance in colorectal cancer.Methods MiR-217 expression was detected in 30 cases of colorectal cancer tissues and corresponding adjacent normal colorectal tissues by qRT-PCR.The clinicopathologic correlations of miR-217 expression were performed using Fisher's exact test.Kaplan-Meier method was used to evaluate the overall survival of patients.Results MiR-217 was significantly lower in colorectal cancer tissues than in normal colorectal tissues (P ＜ 0.01).Moreover,the decreased miR-217 level was significantly associated with tumor size and TNM stage,as well as lymph node and distant metastasis.Meanwhile,patients of colorectal cancer with low levels of miR-217 expression had a significantly shorter median survival (x2 =4.584,P ＜ 0.05) than those with high levels of miR-217 expression.Conclusions Downregulated miR-217 in colorectal cancer tissues correlates to poor prognosis in postoperative colorectal cancer patients.

In-vitro study of glycogen synthase kinase-3β on regulation of migration, invasion and epithelial-mesenchymal transition in pancreatic cancer cells / 中华普通外科杂志

Objective To explore the role of GSK-3β in migration,invasion,metastasis and epithelial-mesenchymal transition of pancreatic cancer in vitro.Methods Lentiviral interference was used to inhibit the expression of GSK-3β in pancreatic cancer cells.Western blotting was used to detect expression of GSK-3β phosphorylation molecules and epithelial-mesenchymal transition and invasion related molecule.Scratch test and transwell test were adopted to detect the effect of GSK-3β inhibition on cell migration and invasion in pancreatic cancer cells.Luciferase reporter gene test was used to detect the effect of GSK-3β inhibition on NF-κB binding activity.Results Inhibition of GSK-3β expression significantly restrain migration,invasion and epithelial-mesenchymal transformation.Migration inhibitory rate was 59.1％ ±6.4％ in ASPC-1 group and 55.9％ ± 7.3％ in PANC-1 group.GSK-3β inhibition affected the activity of NF-κB,the binding activity decreased to 24.8％ ± 3.1％ and 31.5％ ±5.4％,respectively (all P ＜ 0.05).Conclusions GSK-3β participates in the regulation of migration,invasion,and epithelialmesenchymal transition of pancreatic cancer.GSK-3β inhibition could surpress proliferation,invasion and epithelial-mesenchymal transformation,and NF-κB might be the key molecule in the regulation of pancreatic malignant behavior.

Individualized surgical treatment for chronic pancreatitis / 中华消化外科杂志

Because of the complex pathogenesis and progressive development,it is difficult to define the optimal surgical time and procedure for chronic pancreatitis.The individualized treatment of chronic pancreatitis should resect the inflammatory mass of the head of the pancreas and preserve the pancreatic parenchyma to postpone the injury of pancreatic function and improve life quality as well as decrease the risk for carcinogenesis of pancreatic cancer.Conservative and endoscopic treatment can be considered in the early stage,while surgical intervention should be applied for chronic pancreatitis with stenosis or obstruction of pancreatic duct and calcification of the pancreatic parenchyma.Frey procedure can be performed on patients only with stone in or dilation of pancreatic duct ; patients with obvious inflammatory mass or calcification of the head of the pancreas should receive Beger procedure to decrease the morbidity of pancreatic cancer.

Efficacy of modified duodenum-preserving pancreatic head resection for chronic pancreatitis / 中华消化外科杂志

Objective To investigate the efficacy of a modified duodenum-preserving pancreatic head resection (DPPHR) for the treatment of chronic pancreatitis.Methods The clinical data of 109 patients with chronic pancreatitis who received modified DPPHR at the Union Hospital of Huazhong University of Science and Technology from January 2004 to June 2013 were retrospectively analyzed.Of the 109 patients,66 were with mass in the head of the pancreas,29 were with calcification of the head of the pancreas,14 were with atrophy of the head of the pancreas and stones in the main pancreatic duct.The level of glucose of 56 patients were normal,34 patients had glucose tolerance abnormalities and 19 were complicated with diabetes mellitus.Modified DPPHR was carried out after confirming the diagnosis of chronic pancreatitis and excluding the malignancies by frozen pathological examination.The head of the pancreas was completely resected.The posterior pancreaticoduodenal aortic arch running parallel to the duodenum was preserved to guarantee the blood supply to the remaining duodenum.A thin sheet of the pancreatic tissue behind the intrapancreatic common bile duct and between the common bile duct and the duodenum was preserved to guarantee the blood supply to the common bile duct.The gastrointestinal tract was reconstructed with an anastomosis of the distal pancreas and the jejunum and an end-to-en anastomosis of the proximal jejunum and the distal jejunum.Patients were followed up via out-patient examination to learn the frequency of abdominal pain,analgesics usage and the endocrine function.The pain scale,life quality and endocrine function were evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30),Gastrointestinal Quality of Life Index (GLQI) questionnaire,and oral glucose tolerance test (OGTT),respectively.Patients were followed up till January 2014.The measurement data and the count data were analyzed using the t test and the chi-square test,respectively.Results No patients died during the operation.The operation time,volume of blood loss and blood transfusion were (3.5 ± 0.7) hours,(360 ± 125) mL and (260 ±220) mL,respectively.After the operation,5 patients were complicated with pancreatic leakage,5 with bile leakage,2 with duodenal fistula and 1 with peritoneal bleeding,and all the patients were cured after conservative treatment.Four patients were complicated with abdominal abscess,1 patient of whom was treated by conservative treatment,and the remaining 3 patients were cured by drainage guided by B sonography.The duration of hospital stay was 13.8 days (range,10.0-32.0 days).The median time of follow-up was 18.0 months (range,3.0-24.0 months).A total of 102 patients were followed up for more than 9 months.At postoperative month 9,the ratio of patients with abdominal pain was decreased from 78.90％ (86/109) to 18.63％ (19/102),and the ratio of patients administered analgesics was decreased from 76.47％ (78/102) to 12.75％ (13/102),with significant difference between the indexes before and after operation (x2=76.57,74.31,P ＜ 0.05).The score of the EORTC QLQ-C30 was decreased from 58 ±36 before operation to 15 ±4 after operation,with significant difference (t =11.39,P ＜ 0.05).The score of GLQI was increased from 69 ± 8 before operation to 87 ± 15 after operation,with significant difference (t =20.05,P ＜ 0.05).The patient with diabetes mellitus was cured,and no newly onset of diabetes was found.Two patients received reoperation because of recurrence of stones in the distal pancreatic duct and pancreatogenic portal hypertension.Conclusion Modified DPPHR is effective for the treatment of chronic pancreatitis with low incidence of postoperative complications.

Management of inoperable advanced pancreatic head carcinoma without gastric outlet obstruction: an analysis of 441 patients / 中华普通外科杂志

Objective To explore the optimal management strategies for unresectable advanced pancreatic head carcinoma without preoperative gastric outlet obstruction(GOO).Methods Clinical data of 441 cases of advanced pancreatic head carcinoma without GOO undergoing surgery from Jan 2001 to Dec 2010 were analyzed retrospectively.Results Among the 441 cases of advanced pancreatic head carcinoma without GOO,101 patients received simple Roux-en-Y cholecystojejunostomy (group A),133 patients received simple Roux-en-Y choledochojejunostomy (group B),83 patients received Roux-en-Y cholecystojejunostomy combined gastrojejunostomy(group C) and the other 124 patients received Roux-en-Y choledochojejunostomy combined gastrojejunostomy (group D).The postoperative recurrent obstructive jaundice rates were 7.9％ and 6.0％ in group A and C,respectively; the postoperative de novo GOO rates were 8.9％ and 8.3％ in group A and B,respectively; there were no differences in median survivals among the four groups (F =1.933,P =0.123).Conclusions Choledochojejunostomy is effective for the reduction of recurrent obstructive jaundice for advanced pancreatic head carcinoma patients without GOO,combined prophylactic gastrojejunostomy during surgical biliary drainage could decrease the rate of postoperative GO0.Cholecystojejunostomy could be only applied for patients with poor health or when choledochojejunostomy is a taboo.

Optimal timing and rational procedure of surgical intervention for severe acute pancreatitis / 中华消化外科杂志

Surgical therapy of severe acute pancreatitis (SAP) has been developed through several stages.The initial active surgery was replaced by conservative treatment followed by selective surgical intervention.Surgical procedures changed from pancreatic capsule incision and pancreatectomy at the early stage to necrosectomy at the later stage.Recently,planned minimally invasive necrosectomy was used to treat SAP patients.Some patients received ultrasound or CT guided drainage initially were finally cured by definitive open necrosectomy.In recent years,more advanced management of SAP developed in multidisiplinary treatment.Therefore,comprehensive treatment of SAP including the indication of surgical intervention at early stage and the optimal timing and the rational method of surgery at the late stage of SAP was discussed.

Effects of AKT2 expression on gemcitabine sensitivity in pancreatic cancer cell line Panc-1 / 中华肝胆外科杂志

Objective To explore the effects of AKT2 expression in pancreatic cancer cell line Panc-1 on the sensitivity towards to gemcitabine.Methods The expression vector pAKT2 shRNA was constructed and transfected into Panc-1 cells by lipofecton.The mRNA and protein expression levels of AKT2 were detected by RT-PCR and Western blot assays,respectively.The changes of gemcitabine sensitivity after shRNA were examined by the MTT assay.Results The mRNA and protein levels of AKT2 in Panc-1 cells were significantly decreased after the transfection,and the median inhibition concentration of gemcitabine against Panc-1 cells was reduced from (1.96 ± 0.22) mg/L to (0.24±0.03) mg/L.The sensitivity of Panc-1 cells to gemcitabine was increased significantly after pAKT2-shRNA transfection.Conclusion The sensitivity of Panc-1 cells to gemcitabine could be enhanced by pAKT2-shRNA.

Effects of insulin on proliferation and invasion of human pancreatic cancer PANC1 cells / 中华胰腺病杂志

ObjectiveTo investigate the effects of insulin on the proliferation and invasion of human pancreatic cancer cells PANC1,and on its HIF-1α,VEGF expression.MethodsPANC1 was pretreated with insulin of different concentrations (0.1,1,10,100 nmol/L).The proliferation of PANC1 was tested by MTTmethod,and transwell assay was used to test the invasion ability of PANC1.HIF-1α,VEGF and PCNA protein expression was assessed by Western blots,and HIF-1α,VEGF mRNA was detected by real-time PCR.Results Insulin could increase the proliferation of PANC1 in a dose-dependent manner (p ＜0.05 ),and increase the expression of HIF-1α,VEGF protein.After 100 nmol/L insulin treatment for4 d,the PCNA protein expression in the insulin group was significantly higher than that in the control group (1.196 ±0.014 vs 1.157 ±0.013,P ＜ 0.05).The cancer cells passed through the chamber in insulin group were much more than that in the control group ( 141.0 ± 2.1 vs 89.0 ± 1.4,P ＜0.05 ).The expression of HIF-1α protein was significantly increased (1.139 ±0.020 vs 0.598 ±0.013,P ＜0.05),while there was no significant change of HIF-1αmRNA expression.Both the expression of VEGF protein and mRNA were significantly increased (1.011 ± 0.023 vs 0.627 ± 0.013 0.970 ± 0.016 vs 0.350 ± 0.01 3,P ＜ 0.05 ).Conclusions High insulin microenvironment could enhance the proliferation and invasion of PANC1 cells by up-regulating the expression of HIF-1α and VEGF.

Effects of early peritoneal puncture and catheter drainage on severe acute pancreatitis / 中华普通外科杂志

ObjectiveTo evaluate the effect on organ function by early peritoneal puncture and catheter drainage for intra-abdominal hypertension during the course of severe acute pancreatitis (SAP).MethodsA retrospective study was conducted on 405 patients of severe acute pancreatitis with IAH at Department of Pancreatic Surgery,Wuhan Union Hospital from January 2001 to September 2010.In the early course of SAP,137 cases did not receive peritoneal puncture and drainage decompression,268 cases were treated with peritoneal puncture and drainage decompression.ResultsThe differences of the scores of UBP and APACHE Ⅱ were statistically significant between the puncture group and the non-puncture group (P ＜ 0.05).The occurrence of ARDS,ARF and MODS in the group of puncture were significantly lower than those of the non-puncture group (14％ vs.27％,21％ vs.32％,9％ vs.14％,respectively,all P ＜0.05 ).At the same time,the differences between rate of early laparotomy and rate of early mortality in the two groups were statistically significant (4％ vs.12％,3％ vs.6％,respectively,all P ＜0.05).However,there was no significant difference in the occurrence time of negative balance in the two groups (5.9 ±2.9 vs.5.9 ± 2.4,P ＞ 0.05 ).ConclusionsEarly abdominal puncture and drainage reduce the abdominal pressure of patients with SAP and IAH.It also reduces the occurrence of organ failure,the rate of early laparotomy and the rate of early mortality in SAP patients.