Application of pancreaticojejunostomy procedures selection strategy in pancreaticoduodenectomy and risk factors analysis of pancreatic fistula after operation / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the pancreaticojejunostomy procedures selection strategy in pancreaticoduodenectomy and to analyze risk factors of pancreatic fistula.</p><p><b>METHODS</b>Clinical data of 352 patients who received pancreaticoduodenectomy from September 2009 to September 2012 were retrospectively analyzed. For patients with soft pancreas, binding pancreaticojejunostomy was applied to 153 patients. For patients with hard pancreas, duct-to-mucosa pancreaticojejunostomy (DMPJ) was applied (199 cases). The clinical efficacy and incidence of postoperative complications were compared among 2 groups. Risk factors of pancreatic fistula were screened out from many factors by univariate and multivariate analysis.</p><p><b>RESULTS</b>The overall incidence of pancreatic leakage was 13.9% (49/352). There were no significant difference in incidences of pancreatic leakage (χ(2) = 0.512), peritoneal bleeding (χ(2) = 0.784), abdominal infection (χ(2) = 1.161), digestive dysfunction rate (χ(2) = 4.753) and mean duration of hospital stay (t = 2.13) among 2 groups (all P > 0.05). The results of multivariate analysis showed pancreatic tube diameter < 3 mm (OR = 5.748), preoperative total bilirubin level > 171 µmol/L (OR = 5.112), duration of preoperative jaundice > 8 weeks (OR = 5.090), preoperative albumin level < 30 g/L (OR = 4.464) were independent risk factors of pancreatic fistula (all P < 0.05).</p><p><b>CONCLUSIONS</b>Bunding pancreatojejunostomy was as good as soft pancreatic; for duct diameter ≥ 3 mm suggested using duct-to-mucosa pancreaticojejunostomy. For the risk factors for pancreatic leakage actively cooperate with preoperative nutritional support and timely treatment of jaundice, the incidence of postoperative pancreatic leakage will be further reduced.</p>

Attach importance to the prevention and treatment of iatrogenic injury in choledocho-pancreatico-duodenal junction / 中华消化外科杂志

Because of the particularity in causes, mecha-nisms and clinical performances, injury in choledocho-pancreatico-duodenal junction is usually doomed with a delayed diagnosis, often leading to a poor prognosis. The early manifestations of bile duct perforation include peritoneal swelling caused by detained water after trans-T-tube injection, blue staining of the field of operation and contrast medium leaking outside the bile duct system, peritoneal or abdominal gas accumulation, pneu-mothorax or subcutaneous emphysema after endoscopic sphincte-rotomy (EST) or endoscopic retrograde cholangiopancreatogra-phy (ERCP). Postoperative high fever, abdomical pain radia-ting to right side back and waist, fluid accumulation in the right iliac fossa or around the right kidney are the associated evidences. If the perforation is discovered during the operation, it should be sutured and choledocal T-tube drainage should be performed. If the perforation is not discovered during the opera-tion, biliointestinal bypass should be constructed. The injuries resulted from ERCP or EST procedures should be treated accord-ing to the detailed situation. Conservative treatment can be given to those who are in relatively stable status. If the condition of the patients deteriorated, timely conversion to laparotomy is needed. For patients with delayed diagnosis, thorough drainage of the region, separation of bile and pancreatic juice, duodenal diver-ticularization and jejunostomy should be considered. The key point in preventing the injury in choledocho-pancreatico-duode-hal junction lies on full knowledge of the anatomy of the region, delicate practice without forceful exploration and detailed exami-nation after the operation to avoid missing diagnosis.

Effects of inducible co-stimulator gene on the cytotoxic activity of cytokine-induced killer cells against cholangiocarcinoma cells / 中华消化外科杂志

Objective To explore the effects of inducible co-stimulator (ICOS) gene on the cytotoxic activity of cytokine-induced killer (CIK) cells against cholangiocarcinoma cells. Methods CIK-ICOS cells were obtained by stable transfecting ICOS genes into CIK cells through the adenovirus vector whereas untransfected and EGFP-transfected CIK cells were treated as controls. The proliferation and apoptosis of different CIK cells, as well as their cytotoxicity against cholangiocarcinoma cells in the three groups were detected. The expressions of IFN-T, IL-2 and TNF-α in the supernatant of different CIK cells were measured by ELISA. SCID mice with cholangiocarcinoma were randomly divided into CIK group, CIK-EGFP group, CIK-ICOS group and normal saline group. The cytotoxic activity of CIK-ICOS cells against cholangiocarcinoma cells in vivo was observed. Results CIK-ICOS cells displayed better proliferation than CIK cells and CIK-EGFP cells. At day 20 and 23 of culture, the apoptosis rate of CIK-ICOS cells was 0.69% and 0.89%, respectively, while that of the CIK cells was 2.90% and 4.92%. The cytotoxic effect of CIK-ICOS cells at different E: T ratio against cholangiocarcinoma cells was significantly stronger than that of CIK cells and CIK-EGFP cells (F=13.37, 6.46, 25.51, P<0.05). The concentration of IFN-γ in CIK-ICOS cultured supernatant was (49.50±4.73)μg/L, which was significantly higher than that in the cultured supernatant of CIK cells [(30.53±3.73)μg/L] and CIK-EGFP cells [(30.12±2.64)μg/L](F=38.89, P<0.05). The growth of cholangiocarcinoma was significantly slower in CIK-ICOS group than that in CIK group and CIK-EGFP group, whereas the necrosis area of tumor was larger and the CIK cells in CIK-ICOS group was more than those in the other two groups. Conclusions CIK cells had the function of killing cholangiocarcinoma cells in vitro and in vivo. After ICOS genes were transfected into CIK cells, the survival time of CIK cells in vitro was prolonged and the proliferation of CIK cells was enhanced, as well as the secretion of IFN-γ was increased so that the cytotoxicity of CIK cells against cholangiocarcinoma cells in vitro and in vivo was enhanced.

Selection of surgical procedures for cholangiocarcinoma and the corresponding prognosis / 中华消化外科杂志

Objective To discuss the relationship between prognosis and different surgical procedures for gallbladder cancer in different stages. Methods The clinical data of 107 patients with gallbladder cancer from January 2001 to May 2007 were retrospectively analyzed. The surgical procedure was chosen according to different stages. Results Eighty-one of the 107 patients (75.6%) were followed up with the median time of 5 years. Of the 10 patients with stage Ⅰ gallbladder cancer who had underwent simple cholecystectomy, 9 survived. Of the 8 patients with stage Ⅱ gallbladder cancer, 3 received palliative cholecystectomy and the median survival time was 12 months, which was significantly shorter than 24 months of the remaining 5 patients who received radical operation (X2= 5.698, P <0.05). Of the 42 patients with stage Ⅲ gallbladder cancer, 18 received radical operation, and the median survival time was 24 months, which was not significantly different from 18 months of the 5 patients who received extended radical operation (X2=0.238, P>0.05). The remaining 19 patients received palliative operation, and the median survival time was 6 months, which was significantly shorter than those of patients received radical operation or extended radical operation (X2=5.772, 6.318, P <0.05). There were 47 patients with stage Ⅳ gallbladder cancer. Seventeen patients received extended radical operation and 30 received palliative operation, and no significant difference upon the median survival time was observed among different surgical procedures (X2=0.001,0.694, P>0.05). The complication recurrence after the extended radical operation was significantly higher than palliative operation (X2=6.039, P<0.05). Conclusions For patients with stage Ⅰ gallbladder cancer, simple cholecystectomy is preferred. Radical operation is good for patients with stage Ⅱ gallbladder cancer. The choose of radical operation or extended radical operation for patients with stage Ⅲ gallbladder cancer should be based on the condition of invasion. Palliative operation could be used to patients with stage Ⅳ gallbladder cancer.