Current status and prospects of neoadjuvant therapy for resectable pancreatic cancer / 中华外科杂志

Pancreatic cancer is a highly malignant tumor. About 75% of patients with pancreatic cancer who underwent radical surgical resection will still experience postoperative recurrence. Neoadjuvant therapy could improve outcomes in patients with borderline resectable pancreatic cancer,has become a consensus;however it is still controversial in resectable pancreatic cancer. Limited high-quality randomized controlled trial studies support the routine initiation of neoadjuvant therapy in resectable pancreatic cancer. With the development of new technologies, such as next-generation sequencing, liquid biopsy, imaging omics, and organoids, patients are expected to benefit from the precision screening of potential candidates for neoadjuvant therapy and individualized treatment strategy.

How to standardize the enhanced recovery after surgery in clinical practice? / 中华胃肠外科杂志

The enhanced recovery after surgery (ERAS) protocol is an evidence-based perioperative care pathway, which is to reduce the perioperative stress and metabolic variation, with the ultimate goal of improving patient recovery and outcomes. This article reviews some hot issues in the clinical practice of ERAS in China. Currently, the concept and pathways of ERAS are very consistent with China's medical reform, and the basic principle of "safety first, efficiency second" should be adhered to. In specific clinical practice, multidisciplinary cooperation, the improvement of surgical quality and the implementation of prehabilitation pathway should be advocated. In addition, the ERAS approaches should be implemented individually to avoid mechanical understanding and dogmatic implementation. The implementation of ERAS and its clinical outcome should be audited to accumulate experience, and a feedback mechanism should be established to improve the outcome continuously. In clinical practice, "fast recovery" should not be the sole purpose. For patients, the decrease in the risk of readmission rate is more important as compared to discharge rate. Additionally, the disparities between the development of ERAS clinical research in China and that in the world are also analyzed in this review. A national ERAS database should be established on the basic platform of academic groups to ensure the development of high-quality clinical research in China.

Principles and recent progress in surgical treatment of pancreatic neuroendocrine neoplasms / 中国实用外科杂志

Pancreatic neuroendocrine neoplasms(pNENs)are a relatively rare group of heterogeneous tumors with malignant potential originating from pancreatic neuroendocrine cells.Most pNENs grow slowly with an inert biological behavior,and the surgical resection rate and longterm survivalis much better than those of pancreatic ductal adenocarcinoma.Surgery is the only curable way for treatment of pNENs.Surgical approaches should be selected based on the patient's age and physical condition,the grading classification and TNM staging of the tumor,the location of the tumor and its distance to the pancreatic duct,the invasion of surrounding organs,and distant metastasis.Even palliative resection of either the primary tumor or the metastatic lesions may be beneficial for the survival of late staged pNENs patients.

The diagnosis and management strategies for gastrointestinal hemorrhage following pancreaticoduodenectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the causes and clinical features of gastrointestinal hemorrhage following pancreaticoduodenectomy (PD), and to provide the management strategies for this complication.</p><p><b>METHODS</b>The clinic data of 412 patients who underwent PD from January 2000 to April 2010 was retrospectively reviewed. There were 232 male and 180 female patients, average age was (60 ± 12) years. The mode of procedure was standard PD and the Child's reconstruction of digestive tract, whose anastomosic steps encluded gastroenterostomy following chlangioenterostomy and pancreaticoenterostomy, was employed. Etiology of gastrointestinal haemorrhage, diagnostic methods and treatment strategy was recorded and analyzed.</p><p><b>RESULTS</b>The postoperative mobidity was 37.1% (153/412), the rate of haemorrhagic complications was 6.6% (27/412), and gastrointestinal hemorrhage was recorded in 11 patients (2.7%). The bleeding rate of pancreaticointestinal anastomosis and gastricointestinal anastomosis were 5/11 and 4/11, respectively. Among these 11 patients, early hemorrhage occurred in 6 patients, 7 patients were due to technical failure. In order to control this kind of complication, open abdominal operation alone was performed on 4 patients, endoscopic management was performed on 3 patients and succeeded in 2 patients, vascular interventional therapy was performed on 5 patients and succeeded in 2 patients, and Re-laparotomy following vascular interventional therapy was performed on 2 patients successfully.</p><p><b>CONCLUSIONS</b>Gastrointestinal hemorrhage following PD always occurred in early stage and reliable hemostasis during operation is the key points for prevention. Angiography is minimally invasive and holds the diagnostic value. Timely and decisive reoperation is an important method to management of postoperative gastrointestinal hemorrhage.</p>

Individualized surgical treatment and prognosis of intraductal papillary mucinous neoplasms of the pancreas / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the clinical manifestation, individualized surgical treatment, and prognosis of intraductal papillary mucinous neoplasms (IPMN) of pancreas.</p><p><b>METHODS</b>The clinical data of 56 IPMN cases treated between January 2007 and December 2011 was retrospectively analyzed. Among the 56 patients (38 male and 18 female, mean age (61 ± 7) years), 26 were main-duct type, 18 were branch-duct type, 12 were mixed type. Pancreatectomy was performed on 48 cases, including pancreaticoduodenectomy on 29 patients, distal pancreatectomy on 17 patients, and total pancreatectomy on 2 patients.</p><p><b>RESULTS</b>The overall postoperative morbidity rate was 27.1% (13/48), there was no perioperative mortality. Pathology showed 31 cases of noninvasive IPMN, 17 cases of invasive IPMN, and 7 cases of lymph node metastasis. The rate of invasive tumors was 46.2% (12/26) in main duct type, 3/12 in mixed type, and 2/18 in branch duct type IPMN, the difference was statistically significant (χ(2) = 6.385, P = 0.041). The five-year survival rate for patients with noninvasive and invasive neoplasms was 100% and 24.6%, respectively. The prognosis of invasive cases with lymph node metastasis was significantly worse than those without lymph node metastasis (P = 0.017). A regular follow-up without surgical treatment was performed on 8 cases with asymptomatic side branch IPMN less than 3 cm in diameter, and no progression was found during the follow-up.</p><p><b>CONCLUSIONS</b>IPMN has a relative good prognosis. Main duct type and mixed type IPMN have a higher malignant potential, and should receive a surgical treatment. Patients of branch duct type IPMN with a <3 cm diameter lesion and no clinical manifestations can be managed with close follow-up only.</p>

Factors associated with post-pancreaticoduodenectomy hemorrhage: 303 consecutive cases analysis / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Because of the complexity and severity of the surgery and its associated complications, pancreaticoduodenectomy (PD) is associated with significant morbidity and mortality, especially the hemorrhage post-PD. Exploring the factors associated with post-PD hemorrhage is very important for the patients' safety.</p><p><b>METHODS</b>Clinical data from 303 cases of PD between January 1998 and December 2008 were analyzed retrospectively.</p><p><b>RESULTS</b>The overall mortality rate was 4.95% (15/303). However, post-operative bleeding occurred in 25 patients (8.25%) with nine episodes resulting in death (36.00%). Univariate analysis was performed and identified tumor size, Child's classification, total pancreatic uncinatic process resection, and pancreatic leakage as significant risk factors for post-PD hemorrhage. In the severe hemorrhage group, incomplete resection of uncinate process of pancreas and pancreatic leakage were the main causes. The multivariate Logistic regression analysis revealed that each of these variables is an independent risk factor.</p><p><b>CONCLUSIONS</b>Primary prevention of bleeding complications depends on total pancreatic uncinatic process resection and meticulous hemostatic techniques during surgery. In addition, several peri-operative factors were found to contribute to post-PD bleeding.</p>

Influential factors and effect evaluation of the intra-operative puncture biopsy for pancreatic masses / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>It is a challenge for the surgeons to accurately diagnose the pancreatic masses preoperatively, which decides the choice of surgical managements and subsequently results in different survivor outcomes, operative complications, and mortality rates. The purposes of this study were to evaluate the diagnostic role that intra-operative puncture biopsy may play in pancreatic masses and to explore the relevant factors influencing the diagnosis.</p><p><b>METHODS</b>A retrospective study was performed on 94 in-patients admitted to Peking University First Hospital for pancreatic masses during the period from June 1994 to December 2007. They all underwent intra-operative puncture biopsy during exploratory laparotomy. The sensitivity and specificity of intra-operative puncture biopsy were calculated and the relevant factors to the diagnosis of biopsy were selected for the statistical analysis.</p><p><b>RESULTS</b>The overall sensitivity, specificity, positive predictive value, and negative predictive value of intra-operative puncture biopsy were 76.0%, 94.7%, 98.3% and 50.0%, respectively. The analysis of bivariate correlations showed that the size of the pancreatic masses (P = 0.000), the number of puncture biopsies (P = 0.000), and the presence of pancreatic fibrosis (P = 0.012) had statistic significance for the diagnosis. But the multivariate analysis identified the size of the pancreatic masses (P = 0.004) and the number of puncture biopsies (P = 0.000) as independent predictive factors for intra-operative puncture biopsy. In addition, as the number of puncture biopsies increased, the sensitivity and specificity of diagnosis was improved (P = 0.000). The sensitivity and specificity of intra-operative puncture biopsy were found to be lower for the pancreatic masses less than 25 mm compared with the masses larger than 25 mm (P = 0.000). It was noted, however, that even if the masses were less than 25 mm, the sensitivity and specificity could be improved significantly as the number of puncture biopsies reached 3 to 6 (P = 0.007).</p><p><b>CONCLUSIONS</b>Intra-operative puncture biopsy is simple and accurate for qualitatively differentiating various types of pancreatic masses. Three to 4 biopsies could significantly improve the diagnostic effect for pancreatic masses, even if the masses are less than 25 mm in size.</p>

Surgical complications after pancreatoduodenectomy: risk factors and treatments / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the impact factors and treatment of post pancreatoduodenectomy complications.</p><p><b>METHODS</b>The clinical data of 412 cases between January 1995 and April 2010 underwent pancreatoduodenectomy were analyzed retrospectively. There were 232 male, 180 female. Univariate and multivariate logistic regression model were used to identify the risk factors related to occurrence of postoperative complications.</p><p><b>RESULTS</b>The overall postoperative morbidity rate was 37.1% (153/412), and mortality rate was 4.6% (19/412). Total uncinate process resection, type of pancreatic-enteric anastomosis, duct diameter and pancreatic texture had effects on postoperative pancreatic fistula statistically. Total uncinate process resection, the amount of intra-operative blood loss ≥ 600 ml and pancreatic fistula were identified as significant risk factors for post pancreatoduodenectomy hemorrhage by means of univariate analysis. Delayed gastric empting occurrence in the patients with pylorus-preserving pancreaticoduodenectomy was higher than those with standard pancreaticoduodenectomy significantly. The multivariate Logistic regression analysis revealed that duct diameter and pancreatic texture were the independent risk factors of pancreatic fistula. Total uncinate process resection, the amount of intra-operative blood loss ≥ 600 ml and pancreatic fistula were independent risk factors of bleeding. There were no statistically significant differences between the radical group and the standard group when postoperative complication rates were analyzed (P < 0.05).</p><p><b>CONCLUSIONS</b>Pancreaticojejunal anastomoses by means of duct-to-mucosa is fit for the patients with dilated pancreatic duct and end-to-end invaginated pancreaticojejunostomy is fit for the patients with undilated pancreatic duct. The prevention of postoperative bleeding depends on total uncinate process resection and meticulous hemostatic technique during operation. The pancreatic fistula is one of the most important factors which can result in postoperative bleeding. Pancreaticoduodenectomy combines with SMV/PV resection and extended lymphadenectomy do not significantly increase the morbidity rates.</p>

Extrahepatic synthesis of coagulation factor VII by colorectal cancer cells promotes tumor invasion and metastasis / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Blood coagulation factor VII (FVII) is physiologically synthesized in the liver and released into the blood. Binding of FVII to tissue factor (TF) is related to the metastatic potential of tumor cells, also a significant risk factor in the development of hepatic metastasis in patients with colorectal cancer (CRC). It has been found that some cancer cells can produce FVII extrahepatically. However, little is known about FVII and CRC. We therefore hypothesized that CRC cells may synthese FVII, leading to tumor invasion and metastasis.</p><p><b>METHODS</b>We detected the expression of FVII protein in 55 CRC specimens by immunohistochemical staining. The FVII mRNA in 45 of 55 CRC cases, 6 colon cancer cell lines and one hepatoma cell line was measured by real-time reverse transcription-PCR (RT-PCR). Transwell invasion assays were performed to evaluate the changes of cell migration and invasion of LoVo cancer cells in vitro. We further observed the likely effectors regulated by the TF/FVIIa complex Western blotting assay.</p><p><b>RESULTS</b>Extrahepatic synthesis of FVII was detected in the cytoplasm of 32 (58.2%) CRC specimens by immunohistochemistry, but not in normal mucosa. Liver metastasis (P = 0.003) and TNM staging (P = 0.005) were significantly correlated with FVII antigen expression. The positive ratios in stages I, II, III and IV were 33.3%, 40.0%, 52.4% and 87.5%, respectively. The expression of FVII mRNA in CRC with hepatic metastasis was significantly higher than CRC without hepatic metastasis (5.33 ± 2.88 vs. 1.47 ± 0.51, P = 0.03). Ectopic FVIIa induced a slight increase (1.34-fold) in the number of migrating cells, which was inhibited by the specific TF antibody. The formation of TF/FVIIa complex resulted in a marked increase in the expression of matrix metalloproteinases (MMP)-2 (3.5-fold) and MMP-9 (4.7-fold) in a time-dependent and dose-dependent manner.</p><p><b>CONCLUSIONS</b>Extrahepatic synthesis of FVII by CRC cells may promote tumor invasion and metastasis. MMPs, as downstream effectors of TF/FVIIa signaling, facilitate the development of metastasis in colon cancer.</p>

Surgical treatment and prognosis analysis of localized retroperitoneal Castleman disease: a study of 20 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the clinical characteristics, surgical treatment and prognosis analysis of localized retroperitoneal Castleman disease (CD), and to improve the level of diagnosis and treatment of retroperitoneal Castleman disease with paraneoplastic pemphigus (PNP).</p><p><b>METHODS</b>The clinical data of retroperitoneal CD with PNP from January 1993 to May 2009 were compared with CD without PNP retrospectively, including clinical features, tumor site, lab examination, surgical treatment, pathologic subtype and results of surgery.</p><p><b>RESULTS</b>(1) Retroperitoneal Castleman disease more likely originated in para-kidney and iliac fossa with middle age of 36 years old, especially in left retroperitoneum. Of the 20 cases, 18 tumors (90%) were hyaline vascular variants and 2 were mixed variants. There was no statistical difference in gender, age, tumor site and pathological subtype between two groups. (2) Retroperitoneal CD with PNP more likely complicated with bronchiolitis obliterans (BO) and high level of serum CEA/CA242. (3) Retroperitoneal Castleman tumors had clear margin, intact envelop and were easily resectable, however the biological behavior of CD with PNP might tend malignant changing, invade adjacent blood vessel or seed locally, and eventually relapse after operation. (4) The 5-year survival rate of retroperitoneal CD with PNP was 42.8%, significantly lower than those without PNP. The average survival time was 30 months. Bronchiolitis obliterans and radical resection were the key effect in prognosis of retroperitoneal CD.</p><p><b>CONCLUSIONS</b>Retroperitoneal CD with PNP has distinctive clinical features. Early diagnosis, prompt removal of tumor and termination secretion of causative antibody are critical to the management of this disease.</p>

The diagnosis and surgical management for patients with variants of hepatic arteries in the procedure of pancreaticoduodenectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To study the principle and surgical managements for the patients with anatomic variants of hepatic artery in the procedure of pancreaticoduodenectomy (PD).</p><p><b>METHODS</b>One hundred and seventy-six patients who underwent PD between January 2000 and July 2007 were investigated retrospectively. Hepatic arterial variants were analyzed according to the intraoperative finding and CT imaging were reviewed postoperatively.</p><p><b>RESULTS</b>Hepatic arterial variants were found intraoperatively in 20 cases of all 176 patients. Accessory right heptic artery, replaced right heptic artery and common heptic artery arising from the superior mesenteric artery (SMA) were present in 9 (5.1%), 5 (2.8%), 4 (2.3%) cases respectively,and replaced right heptic artery coming from the gastroduodenal artery was present in 2 cases (2.9%). All the variants of hepatic arteries arising from the superior mesenteric artery could be observed in spiral CT imaging. Most of the variant arteries were dissected intact intraoperatively except 2 cases with accessory right heptic artery arising from SMA.</p><p><b>CONCLUSIONS</b>Performing CT scan preoperatively, especially CTA,is effective to diagnose these disorders. Skillful surgical techniques can manage the anatomic variants safely.</p>

Clinical analysis of post pancreatoduodenectomy hemorrhage / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the factors of post pancreatoduodenectomy hemorrhage.</p><p><b>METHODS</b>The clinical data of 263 cases between January 1998 and April 2008 underwent pancreatoduodenectomy were analyzed prospectively.</p><p><b>RESULTS</b>The overall mortality rate was 4.94% (13/263). Postoperative bleeding occurred in 23 patients (8.75%), with 8 episodes ending fatally (34.8%). The tumor size, Child classification, caput total resection and pancreatic leakage were identified as significant risk factors for post pancreatoduodenectomy hemorrhage by means of univariate analysis. The multivariate Logistic regression analysis revealed that all of the five factors turned out to be the independent risk factors.</p><p><b>CONCLUSIONS</b>The prevention of these bleeding complications depends in the first place on meticulous hemostatic technique. The pancreatic leakage is also one of the most important factors due to postoperative bleeding. The prophylactic use of somatostatin is not necessary.</p>

The effect of celecoxib on tissue factor expression in pancreatic cancer cells / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Tissue factor (TF) is overexpressed in many malignant tumours and is linked to the pathogenesis and prognosis of such malignancies. In vitro studies have proved that reduced expression of TF has inhibitory effect on the angiogenesis and cell proliferation of the malignant tumour. Therefore, TF suppression has been raised as a possible treatment for malignant tumours. Here we investigated the effect of celecoxib on TF expression induced by tumour necrosis factor alpha (TNFalpha) in PANC-1 cells and a possible molecular mechanism underlying the celecoxib effect.</p><p><b>METHODS</b>Various doses of celecoxib solution were added to standard cell numbers of PANC-1 cells mixed with equal dose of TNFalpha for 6 hours. The expression of tissue factor was detected quantitatively by Western blot, whilst the activation of nuclear factor kappaB was tested by electromobility shift assay.</p><p><b>RESULTS</b>As the doses of celecoxib increased, the tissue factor expression was decreased in PANC-1 cells and so was the activation of nuclear factor kappaB.</p><p><b>CONCLUSIONS</b>Celecoxib can downregulate the expression of tissue factor induced by TNFalpha in PANC-1 cells. This antitumour effect of celecoxib can be explained indirectly via its suppressive role in activation of nuclear factor kappaB.</p>

Influencing factor analysis of delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the influencing factors of delayed gastric emptying (DGE) after pylorus-preserving pancreaticoduodenectomy (PPPD) and its preventing managements.</p><p><b>METHODS</b>Forty-two patients who underwent PPPD and 104 patients underwent standard Whipple procedure (SPD) between January 2000 and July 2006 were investigated retrospectively. The factors influencing the development of DGE following PPPD were analyzed statistically.</p><p><b>RESULTS</b>There was no significant difference in mortality between PPPD and SPD (0/42 vs. 7/104, P = 0.193). Pancreatic fistula occurred much more frequently in SPD than in PPPD (29/104 vs. 1/42, P < 0.05). The occurrence of DGE after PPPD was higher significantly than that after SPD (35.7% vs. 18.3%, P = 0.024). More DGE occurred in patients with a operation time more than 6 hours than in patients whose operation lasted less than 6 hours (76.9% vs. 17.2%, P = 0.008). Meanwhile, DGE occurred in 20% of patients with the antero-colonic route for duodenojejunostomy and in 50% with retro-colonic route (P = 0.043). Multivariate analysis by logistic regression model showed postoperative intra-abdominal complications were not risk factors for DGE. Prophylactic use of somatostatin couldn't prevent DGE effectively.</p><p><b>CONCLUSIONS</b>DGE is the most frequent postoperative complication after PPPD, it can be markedly reduced by shortening operative time and using antero-colonic duodenojejunostomy procedure. There is no medicine which could prevent DGE effectively.</p>

The diagnosis and treatment for chronic pancreatitis complicated by non-calculous obstructive jaundice / 中华外科杂志

<p><b>OBJECTIVE</b>To study the characters of chronic pancreatitis complicated by non-calculous obstructive jaundice, and discuss the methods for differentiation and treatment.</p><p><b>METHOD</b>Twenty cases selected from January 1985 to December 2004 were analysed in the fields of differentiation and treatment.</p><p><b>RESULTS</b>All cases didn't present with typical clinical presentations and radiological features. Jaundice was presented as the main complaint. Stricture of the intra-pancreatic common bile duct was the symbolic radiological feature. Pancreatic disseminated inflammation was verified pathologically in these cases. CT, ultrasound, EUS, ERCP, MRCP and antigen-marker of neoplasm failed to offer the data for differentiation. The diagnosis could only be determined by pathological exam. The obstructive jaundice could be solved by biliary-enteric anastomoses successfully.</p><p><b>CONCLUSIONS</b>The patients with sole complaint of obstructive jaundice account for 15% of all inpatients with chronic pancreatitis. There exists a direct relationship between the jaundice and the pancreatic inflammation. This disorder should be differentiated from total pancreatic carcinoma, but few differentiated material could be offered by preoperative studies. Pathological result derived from the tissue sample obtained within the exploration would be reliable for diagnosis. The bypass between biliary tract and intestine would be a safe and economical treatment method.</p>

Outcome of extended retroperitoneal lymphadenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas / 中国医学科学院学报

<p><b>OBJECTIVE</b>To evaluate the clinical outcome of extended retroperitoneal lymphadenectomy as surgical therapy for adenocarcinoma of the head of the pancreas.</p><p><b>METHODS</b>Twenty patients with adenocarcinoma of the head of the pancreas were treated by standard pancreatoduodenectomy (standard group) between 1994 and 1997, and 46 patients with the same disease underwent extended retroperitoneal lymphadenectomy associated with standard pancreatoduodenectomy (radical group) between 1998 and 2002. Clinical and pathological parameters in both groups were reviewed. The postoperative morbidity, mortality, and survival data were compared.</p><p><b>RESULTS</b>The mean total number of lymph nodes resected was significantly higher in the radical group than in the standard group (P < 0.05). Of the 46 patients in the radical group, 26.09% (12/46) had metastatic adenocarcinoma in the resected retroperitoneal lymph nodes. There was one perioperative death in the standard group and two in the radical group. Postoperative diarrhea and lymphatic leakage were only observed in the radical group. Transfusion requirements and postoperative morbidity did not differ between the two groups. The 1-, 2-, and 3-year survival rates were 63.16%, 31.58%, and 21.05% in the standard group, and 65.91%, 37.71%, and 21.21% in the radical group (P > 0.05). When the subgroups of patients with positive lymph nodes were analyzed, the 1-, 2-, and 3-year survival rates were 41.67%, 16.67%, and 8.33% in the standard group, and 64.52%, 32.26%, and 12.9% in the radical group (P < 0.05). A trend toward a better survival was observed in the first 2 years after operation in the radical group, but with no significant differences 2 years later.</p><p><b>CONCLUSION</b>The addition of an extended lymphadenectomy may improve the early survival without increasing the morbidity, but has no significant effect on long-term survival.</p>

Classification and choice of surgical procedures for chronic pancreatitis / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the classification, choice of surgical procedures and the clinical outcome of surgical management for chronic pancreatitis.</p><p><b>METHODS</b>54 patients with chronic pancreatitis undergoing operation in our hospital from 1983 to 2004 were analyzed retrospectively, who were divided into chronic calcifying pancreatitis and chronic obstructive pancreatitis according to the clinical manifestations.</p><p><b>RESULTS</b>There were 41 men (76%) and 13 women (24%) with a mean age of 54 years. The cause of chronic pancreatitis was alcohol related in 25 cases (46%), cholelithiasis in 21 (39%), and previous episodes of acute pancreatitis in 18 (33%). Clinical manifestations included abdominal pain in 38 cases (70%), obstructive jaundice in 27 cases (50%). There existed a significant difference in some clinical materials between the two groups of chronic calcifying pancreatitis and chronic obstructive pancreatitis, which might mean the different pathologic basis in the two kinds of chronic pancreatitis. A total of 34 patients underwent nine different operations without perioperative deaths. Both the Puestow procedure and the pancreatoduodenectomy was safe and achieved pain relief in a large percentage of patients, which could also improve the exocrine function whereas the endocrine function remained unchanged. Addition of biliary bypass to the Puestow procedure was suitable for the patients with stenosis of common bile duct. Jaundice was the main manifestation in the patients with the inflammatory mass in the head of the pancreas and Whipple's procedure or other resectional procedures should be performed for them. Only drainage of bile duct had a better outcome for the relief of jaundice, but its effect to pancreas need to be further evaluated.</p><p><b>CONCLUSION</b>The clinicopathologic characteristics of obstructive chronic pancreatitis was more variable and the surgical management should be also different for individuals.</p>

Outcome of pancreaticoduodenectomy with extended retroperitoneal lymphadenectomy for adenocarcinoma of the head of the pancreas / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Nowadays, there is a remarkable rise in resectability rate of periampullary adenocarcinoma and the mortality and morbidity of the pancreaticoduodenectomy procedure have been reduced remarkably, while the 5 year survival rates of patients with carcinoma of the head of the pancreas are still below 25%. We conducted this retrospective study to evaluate the clinical outcome of radical pancreaticoduodenectomy with extended retroperitoneal lymphadenectomy as a surgical therapy for adenocarcinoma of the head of the pancreas.</p><p><b>METHODS</b>Twenty cases with adenocarcinoma of the head of the pancreas were treated by standard pancreaticoduodenectomy (removing only the peripancreatic lymph nodes en bloc with the tumour) from 1994 to 1997, and 46 cases with the same disease underwent extended retroperitoneal lymphadenectomy associated with standard pancreaticoduodenectomy from 1998 to 2002. The patients for whom there were insufficient follow-up data, or who had received postoperative adjuvant therapy, were excluded from the analysis. Clinical and pathological parameters of both groups were reviewed. The postoperative morbidity, mortality and survival data were compared statistically.</p><p><b>RESULTS</b>Demographic and histopathological characteristics were similar in the two groups of patients. Performance of the extended lymphadenectomy lengthened the procedure. The mean total number of lymph nodes resected was significantly higher in the radical group (P < 0.05). Of the 46 cases in the radical group, 26% (12/46) had metastatic adenocarcinoma in the resected retroperitoneal lymph nodes. There was one perioperative death in the standard group, and two in the radical group. Postoperative diarrhoea and lymphatic leakage were only observed in the radical group. Transfusion requirements and postoperative morbidity rates did not differ between the two groups. The 1-, 2- and 3-year survival rates were 63%, 32% and 21% respectively in the standard group, and 66%, 38% and 21% in the radical group. No statistically significant difference was found between the groups. When subgroups of node positive patients were analysed, the 1-, 2- and 3-year survival rates were 42%, 17% and 8% respectively in the standard group, and 65%, 32% and 16% in the radical group. Better survival was observed in the first 2 years after operation in the radical group, but no survival differences were seen after 2 years post operation.</p><p><b>CONCLUSIONS</b>The addition of an extended lymphadenectomy to a pancreaticoduodenectomy did not significantly increase morbidity rates, but was associated with an early survival advantage.</p>

Intraoperative 125I brachytherapy combined with chemotherapy for pancreatic cancer / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To evaluate the efficacy, toxicity and survival of intraoperative 125I brachytherapy combined with chemotherapy for advanced pancreatic cancer.</p><p><b>METHODS</b>Thirty-six patients with advanced pancreatic cancer were randomized to two groups: brachy-chemotherapy group (n = 18) and control group (n = 18). For the combined group, intraoperative 125I implantation and gemcitabine, 5-Fu were given. For the control group, intratumoral injection of absolute alcohol was done.</p><p><b>RESULTS</b>The CR + PR rate of brachy-chemotherapy group was 38.9% with pain relief in 77.8%, while that of control group was 0 with pain relief in 22.2% (P < 0.05). Although there were some toxicity in brachy-chemotherapy group, treatment was well tolerated. The 6-, 12-month survival rates of brachy-chemotherapy group were 71.4% and 21.4% and those of control group were 38.5% and 7.7%, respectively. The median survival time was 10.6 months and 5.2 months for the two groups, between which the difference was significant (P < 0.05).</p><p><b>CONCLUSION</b>Interoperative 125I brachytherapy combined with chemotherapy for advanced pancreatic cancer can control tumor, relieve pain and improve quality of life. It is safe and effective.</p>

Treatment of paraneoplastic pemphigus with Castleman's disease / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the clinical findings and treatment of paraneoplastic pemphigus (PNP) with Castleman's disease.</p><p><b>METHODS</b>To investigate the clinical, histopathologic and CT findings of 8 cases paraneoplastic pemphigus with Castleman's disease.</p><p><b>RESULTS</b>All of 8 patients were diagnosed PNP first and were found Castleman's tumor incidently during routine examination. All 8 cases showed severe erosion or ulcer of the oral mucosa with various skin lesions. Histopathologically, there were intraepidermal acantholytic vesicle, basal cell liquefaction, necrotic keratinocytes in the epidermis and lymphocyte infiltration in the upper dermis. CT scan appeared solitary mass in these patients. Some of them were attacked by bronchiolitis obliterans. All 8 patients were failed by use of predisone. Obvious relief of PNP and pulmonary lesion occurred after tumor was rescted.</p><p><b>CONCLUSIONS</b>Paraneoplastic pemphigus with Castleman's disease is a rare disease. The key step is to find and resect the tumor in abdomen. CT scan should be used to detect the tumor in patients with PNP, especially, when predisone was failed in treatment.</p>