Prospective study on the effect of prophylactic octreotide administration in preventing pancreatic fistula after pancreatoduodenectomy / 中华胰腺病杂志

Objective:To evaluate the effect of prophylactic octreotide administration on pancreaticoduodenectomy (PD)associated postoperative pancreatic fistula (POPF), total complications, peri-operative death and postoperative in-hospital days.Methods:From January 2020 to August 2021, 148 patients who underwent PD in the Department of Biliary-Pancreatic Surgery in Ren Ji Hospital affiliated with School of Medicine of Shanghai Jiao Tong University were recruited into this single-center randomized control double-blinded clinical trial. Patients were randomly assigned into octreotide group ( n=74) and control group ( n=74). Octreotide group was subcutaneously injected with 0.1 mg (1 ml) octreotide after preoperative anesthesia, and was subcutaneously injected with the same dose every 8 hours for 5 days, with a total of 16 doses. Control group was injected with 1 ml normal saline in the same way, and relevant clinical data and indicators of the two groups were recorded. The primary endpoint was clinically relevant pancreatic fistula, and the secondary endpoints were total complications, perioperative death and postoperative in-hospital days. Univariate and multivariate logistic regression analysis were used to screen the risk factors of clinically related POPF after PD. Results:120 patients were finally enrolled, including 61 in octreotide group and 59 in control group. There were no significant differences on age, gender ratio, body mass index, preoperative surgery rate of jaundice reduction, preoperative major biochemical indicators, operation time, intraoperative blood loss, pancreatic duct diameter, pancreatic texture and pathological type composition ratio. The total incidence of clinical relevant POPF was 8.3%, and there were no significant differences on biochemical leakage (4.9% vs 8.5%, P=0.435), grade B fistula (4.9% vs 8.5%, P=0.435) and grade C fistula (1.6% vs 1.7%, P=0.981). The total complication incidence (24.5% vs 28.8%, P=0.601), perioperative mortality (0 vs 3.3%, P=0.147) and postoperative in-hospital days (20.6±11.1 d vs 19.5±12.2 d, P=0.633) were not significantly different between two groups. Univariate analysis showed that preoperative serum albumin level <30 g/L( P<0.001) and pathological type of pancreatic ductal adenocarcinoma ( P=0.036) were independent risk factors for POPF after PD, while multivariate analysis found no statistically significant risk factors. Conclusions:Octreotide can neither reduce the incidences of POPF, total complications and postoperative mortality, nor shorten postoperative in-hospital days. However, for patients with preoperative hypoproteinemia and (or) the pathological type of pancreatic duct adenocarcinoma, the prophylactic use of octreotide during PD and after PD may reduce the occurrence of POPF.

Endovascular intervention for late postpancreaticoduodenectomy hemorrhage / 中华普通外科杂志

Objective To evaluate the safety,efficacy of interventional treatment for late postpancreaticoduodenectomy hemorrhage (LPPH).Methods From Jan 2008 to Dec 2017,678 patients underwent pancreaticoduodenectomy (PD).33 patients (4.9％) suffered from LPPH.30 of these 33 patients underwent diagnostic angiography and endovascular treatment,either transcatheter arterial embolization (TAE,n =21) or covered stent placement (CSP,n =9),and the other 3 underwent laparotomy.Results The incidence of LPPH is 4.9％ with a 12％ motality.The most common presentation is bleeding from abdominal drainage (24.2％) and melena (24.2％).The incidence of sentinel bleeding (SB) is 45.5％ and postoperative pancreatic fistula (POPF) is 69.7％.Intra-abdominal infection were identified in 24 patients (72.7％) and the most common pathogenic bacteria is pseudomonas aeruginosa (11/24,45.8％).The mean time between PD operation and LPPH was 17.4 days.In 21 patients receiving TAE,4 got liver damage and 2 with liver abscesses,1 died.The most common site of LPPH is GDA stump and re-bleeding occurred in 5 patients.9 patients by CSP got bleeding under control.In all 7 re-bleeding patients,2 were saved by CSP,1 was saved by TAE,while the other 4 died.Conclusion Early intervention plays an important role for LPPH.CSP is better than TAE.

Diagnosis and treatment of biliary pancreatic duct dilatation / 中华消化外科杂志

Objective@#To summarize the diagnosis and treatment of biliary pancreatic duct dilatation.@*Methods@#The retrospective and descriptive study was conducted. The clinical data of 22 patients with biliary pancreatic duct dilatation who were admitted to Renji Hospital of Shanghai Jiaotong University School of Medicine between October 2013 to September 2017 were collected. There were 6 males and 16 females, aged from 33 to 82 years, with an average age of 66 years. Surgical exploration was decided according to clinical symptoms, results of laboratory test and imaging examinations. For patients with space occupying lesions, surgical procedure was selected based on results of pathological examination. Patients without surgical exploration or space occupying lesions were allocated into follow-up. Observation indicators: (1) surgical exploration; (2) relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions; (3) surgical treatment; (4) follow-up. Follow-up using outpatient examination was performed on patients up to October 2018. Follow-up was performed on patients with positive surgical exploration to detect postoperative complications.For patients with positive results of imaging examinations, no jaundice, normal laboratory indicators or mild abnormality, liver function, tumor markers and B-ultrasound were re-examined each month, and computed tomography (CT) and magnetic resonance imaging (MRI) was performed once every 3 months. Surgical exploration was performed when total bilirubin (TBil) or tumor markers showed a progressive increase. Follow-up was performed on patients with negative results of imaging examination, jaundice, and mildly elevated CA19-9. TBil and CA19-9 were re-examined monthly, and if they were progressively elevated, patients were transferred to surgical exploration. For patients with negative results of imaging examination, no symptoms, and negative laboratory test, liver function, tumor markers, and B-ultrasound were re-examined once every 3 months, and enhanced CT and MRI were re-examined once every 6 months within one year. Follow-up was performed once every 6 months during the second year, and once a year after two years. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Count data were descibed as absolute numbers, and they were analyzed using the chi-square test under R×C chart or Fisher exact probability.@*Results@#(1) Surgical exploration: of 22 patients, 11 underwent surgical exploration, and 11 underwent follow-up. Of the 11 patients with surgical exploration, 4 were positive for space occupying lesions including 1 of false negative, and 7 were negative for space occupying lesions. (2) Relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions. ① Relationship of clinical symptoms and laboratory test with surgical exploration positive for space occupying lesions: juandice was significantly associated with surgical exploration positive for space occupying lesions (P<0.05), and elevated TBil and DBil were significantly associated with surgical exploration positive for space occupying lesions (χ2=0, 0, P<0.05), with a sensitivity of 75.0% and specificity of 100.0%. ② Relationship between imaging examination and surgical exploration positive for space occupying lesions: results of CT, MRI, endoscopic retrograde cholangio-pancreatography, endoscopic ultrasonography, PET-CT, and combined imaging examinations had no significant association with surgical exploration positive for space occupying lesions (χ2=0, 0.77, 0, 0, 1.00, 0, 0, 0, 0, P>0.05). PET-CT had no significant association with surgical exploration positive for space occupying lesions (P>0.05). ③ Relationship of imaging examination and laboratory test with surgical exploration positive for space occupying lesions: positive imaging examination combined with elevated TBil and CA19-9 was significantly associated with surgical exploration positive for space occupying lesions (P<0.05), with a sensitivity of 50.0% and specificity of 100.0%. ④ Relationship of preoperative diameters of biliary ducts and pancreatic ducts with surgical exploration positive for space occupying lesions: of 22 patients, the diameters of biliary ducts and pancreatic ducts were (13.8±4.3)mm and (4.6±1.5)mm for patients with positive surgical exploration, (13.0±2.8)mm and (3.5±0.5)mm for patients with negative surgical exploration, (11.6±2.4)mm and (3.2±0.4)mm for patients with follow-up, respectively, showing no significant difference between them (t=0.22, 0.36, P>0.05). (3) Surgical treatment: 9 of 11 patients with surgical exploration followed the standard procedure. Of the 9 patients, 4 were found space-occupying lesions at the choledocho-pancreatico-duodenal junction (3 undergoing pancreaticoduodenectomy and 1 undergoing duodenal papilla partial resection), 5 with negative exploration underwent common bile duct incision and T-tube drainage (one patient was unable to pinch the T-tube one month after operation and detected obstruction at the lower end of the bile duct by radiography, and was confirmed pancreatic head cancer by reoperation 3 months after the first operation). Two patients didn′t follow the exploratory procedure, and underwent the child operation only based on the preoperative imaging findings, without intraoperative pathological examination. Postoperative pathological examination showed chronic ampulla and chronic pancreatitis, respectively. (4) Follow-up: 22 patients were followed up for 12-60 months, with a median follow-up time of 36 months. Two of 11 patients with surgical exploration had postoperative gastroplegia, 1 had bile leakage, 1 had incisional infection, and they were improved after symptomatic treatment. Four patients undergoing surgeries for positive exploration had no recurrence during follow-up. Of 5 patients with negative exploration undergoing common bile duct incision and T-tube drainage, 1 was confirmed pancreatic head cancer and underwent pancreaticoduodenectomy, 4 were removed T-tube after by T-tube cholangiography at 2 months after surgery. During the follow-up, no positive signs showed in laboratory test or imaging examination. No recurrence occurred in the two patients undergoing pancreaticoduodenectomy. Of 11 patients with follow-up, 10 had abdominal pain before surgery, including 3 with pain during follow-up and 7 with symptoms disappeared. There was no abnormalities in the laboratory test.@*Conclusions@#The positive imaging examinations combined with jaundice and elevated CA19-9 is an absolute indication for surgical exploration in patients with biliary duct dilatation. Those patients who do not meet this criteria should be distributed into the follow-up. If no positive pathological results were obtained during the operation, the surgery should be terminated and the patients should be transferred into follow-up. The reckless biliary anastomosis or biliary stents placement is opposed.

Prognostic factors of survival for patients with duodenal papilla carcinoma after pancreaticoduodenectomy / 中华普通外科杂志

Objective To investigate the prognostic factors of survival for patients with duodenal papilla carcinoma (DPC) after pancreaticoduodenectomy.Methods 98 DPC patients undergoing pancreaticoduodenectomy with follow-up from Jan 2010 to Dec 2017 at Renji Hospital,School of Medicine,Shanghai Jiao Tong University were analyzed retrospectively.Results 80 Cases were followed up.The 1,3,and 5 year survival rates of 80 patients were 89.9％,72.4％,and 66.6％,respectively.Univariate analysis showed tumor size,T stage,N stage,TNM stage,tissue differentiation degree were related to postoperative survival(all P ＜0.05).Multivariate analysis showed that tumor size,N stage,TNM stage,and tissue differentiation degree were independent factors influencing postoperative prognosis(all P ＜ 0.05).Conclusions Tumor size,N stage,TNM stage and tumor tissue differentiation degree were independent factors influencing the prognosis of DPC after pancreaticoduodenectomy,suggesting that early diagnosis,early treatment and radical resection were the key to improve the postoperative prognosis of DPC.

Diagnosis and treatment of biliary pancreatic duct dilatation / 中华消化外科杂志

Objective To summarize the diagnosis and treatment of biliary pancreatic duct dilatation.Methods The retrospective and descriptive study was conducted.The clinical data of 22 patients with biliary pancreatic duct dilatation who were admitted to Renji Hospital of Shanghai Jiaotong University School of Medicine between October 2013 to September 2017 were collected.There were 6 males and 16 females,aged from 33 to 82years,with an average age of 66 years.Surgical exploration was decided according to clinical symptoms,results of laboratory test and imaging examinations.For patients with space occupying lesions,surgical procedure was selected based on results of pathological examination.Patients without surgical exploration or space occupying lesions were allocated into follow-up.Observation indicators:(1) surgical exploration;(2) relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions;(3) surgical treatment;(4) follow-up.Follow-up using outpatient examination was performed on patients up to October 2018.Follow-up was performed on patients with positive surgical exploration to detect postoperative complications.For patients with positive results of imaging examinations,no jaundice,normal laboratory indicators or mild abnormality,liver function,tumor markers and B-ultrasound were re-examined each month,and computed tomography (CT) and magnetic resonance imaging (MRI) was performed once every 3 months.Surgical exploration was performed when total bilirubin (TBil) or tumor markers showed a progressive increase.Follow-up was performed on patients with negative results of imaging examination,jaundice,and mildly elevated CA19-9.TBil and CA19-9 were re-examined monthly,and if they were progressively elevated,patients were transferred to surgical exploration.For patients with negative results of imaging examination,no symptoms,and negative laboratory test,liver function,tumor markers,and B-ultrasound were re-examined once every 3 months,and enhanced CT and MRI were re-examined once every 6 months within one year.Follow-up was performed once every 6 months during the second year,and once a year after two years.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were descibed as absolute numbers,and they were analyzed using the chi-square test under R×C chart or Fisher exact probability.Results (1) Surgical exploration:of 22 patients,11 underwent surgical exploration,and 11 underwent followup.Of the 11 patients with surgical exploration,4 were positive for space occupying lesions including 1 of false negative,and 7 were negative for space occupying lesions.(2) Relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions.① Relationship of clinical symptoms and laboratory test with surgical exploration positive for space occupying lesions:juandice was significantly associated with surgical exploration positive for space occupying lesions (P＜0.05),and elevated TBil and DBil were significantly associated with surgical exploration positive for space occupying lesions (x2 =0,0,P＜0.05),with a sensitivity of 75.0％ and specificity of 100.0％.(② Relationship between imaging examination and surgical exploration positive for space occupying lesions:results of CT,MRI,endoscopic retrograde cholangiopancreatography,endoscopic ultrasonography,PET-CT,and combined imaging examinations had no significant association with surgical exploration positive for space occupying lesions (x2 =0,0.77,0,0,1.00,0,0,0,0,P＞0.05).PET-CT had no significant association with surgical exploration positive for space occupying lesions (P＞0.05).③ Relationship of imaging examination and laboratory test with surgical exploration positive for space occupying lesions:positive imaging examination combined with elevated TBil and CA19-9 was significantly associated with surgical exploration positive for space occupying lesions (P＜0.05),with a sensitivity of 50.0％ and specificity of 100.0％.④ Relationship of preoperative diameters of biliary ducts and pancreatic ducts with surgical exploration positive for space occupying lesions:of 22 patients,the diameters of biliary ducts and pancreatic ducts were (13.8±4.3)mm and (4.6±1.5)mm for patients with positive surgical exploration,(13.0±2.8)mm and (3.5±0.5) mm for patients with negative surgical exploration,(11.6±2.4) mm and (3.2±0.4) mm for patients with follow-up,respectively,showing no significant difference between them (t =0.22,0.36,P＞0.05).(3) Surgical treatment:9 of 11 patients with surgical exploration followed the standard procedure.Of the 9 patients,4 were found space-occupying lesions at the choledocho-pancreatico-duodenal junction (3 undergoing pancreaticoduodenectomy and 1 undergoing duodenal papilla partial resection),5 with negative exploration underwent common bile duct incision and T-tube drainage (one patient was unable to pinch the T-tube one month after operation and detected obstruction at the lower end of the bile duct by radiography,and was confirmed pancreatic head cancer by reoperation 3 months after the first operation).Two patients didn't follow the exploratory procedure,and underwent the child operation only based on the preoperative imaging findings,without intraoperative pathological examination.Postoperative pathological examination showed chronic ampulla and chronic pancreatitis,respectively.(4) Follow-up:22 patients were followed up for 12-60 months,with a median followup time of 36 months.Two of 11 patients with surgical exploration had postoperative gastroplegia,1 had bile leakage,1 had incisional infection,and they were improved after symptomatic treatment.Four patients undergoing surgeries for positive exploration had no recurrence during follow-up.Of 5 patients with negative exploration undergoing common bile duct incision and T-tube drainage,1 was confirmed pancreatic head cancer and underwent pancreaticoduodenectomy,4 were removed T-tube after by T-tube cholangiography at 2 months after surgery.During the follow-up,no positive signs showed in laboratory test or imaging examination.No recurrence occurred in the two patients undergoing pancreaticoduodenectomy.Of 11 patients with follow-up,10 had abdominal pain before surgery,including 3 with pain during follow-up and 7 with symptoms disappeared.There was no abnormalities in the laboratory test.Conclusions The positive imaging examinations combined with jaundice and elevated CA19-9 is an absolute indication for surgical exploration in patients with biliary duct dilatation.Those patients who do not meet this criteria should be distributed into the follow-up.If no positive pathological results were obtained during the operation,the surgery should be terminated and the patients should be transferred into follow-up.The reckless biliary anastomosis or biliary stents placement is opposed.

Clinicopathological classification and prognostic factors of gastrointestinal neuroendocrine neoplasms: an analysis of 119 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the clinical characteristics, pathological classification and prognostic factors of gastrointestinal neuroendocrine neoplasms (GI-NENs).</p><p><b>METHODS</b>Clinicopathological data of 119 GI-NENs patients at Shanghai Renji Hospital from November 2007 to December 2016 were analyzed retrospectively. According to the classification and grading criteria of the WHO Neuroendocrine Tumor 2010 edition, patients were classified pathologically to realize the malignant degree of tumors. The overall survival rate was calculated by Kaplan-Meier curve, the prognostic risk factors were analyzed by Cox regression model, and the factors including the platelet/lymphocyte ratio (PLR) and neutrophil/lymphocyte ratio (NLR) were included in the analysis in addition to the routine clinicopathological factors.</p><p><b>RESULTS</b>Of 119 patients with GI-NENs, there were 83 cases (69.7%) of male and 36 cases (30.3%) of female. The age of patients ranged from 24 to 86 (median 61) years. Tumor locations included the stomach(n=70, 58.8%), duodenum(n=10, 8.4%), small intestine(n=2, 1.7%), appendix(n=3, 2.5%), colon(n=12, 10.1%), and rectum(n=22, 18.5%). The tumor diameter was 0.6 to 20 cm, the mean diameter was 5.4 cm, and the median diameter was 4 cm. There were 25 cases of G1 neuroendocrine tumor (NET), 7 cases of G2 NET and 87 cases of G3 neuroendocrine carcinoma (NEC). Among the 119 patients, 113 cases (95%) had complete follow-up, and the median follow-up was 75 (1 to 112) months. The 5-years overall survival rate was 58.4%. The survival rate of G1 NET, G2 NET and G3 NEC were 100%, 71.4%, 44.4%, and the difference was statistically significant (P=0.000). Univariate analysis showed that age ≥61 years (P=0.000), tumor located in the stomach, duodenum and colon (P=0.041), tumor size ≥4 cm (P=0.002), pathology classification of G3 NEC (P=0.000), late TNM staging (P=0.000) and blood PLR ≥133 (P=0.017) were associated with lower 5-year survival rate, but blood NLR level was not(P=0.263). Multivariate analysis showed that the patient age (HR=3.036, 95%CI: 1.548 to 5.956, P=0.001), the pathology classification(HR = 1.852, 95%CI:1.099 to 3.122, P=0.021), lymph node metastasis (HR=2.635, 95%CI:1.198 to 5.797, P=0.016) and distant metastasis (HR=2.685, 95%CI:1.383 to 5.214, P=0.004) were independent risk factors affecting the prognosis of patients, but the blood PLR level was not (HR=1.735, 95%CI: 0.947 to 3.176, P=0.074).</p><p><b>CONCLUSIONS</b>The malignant degree of GI-NEN is quite high, and the prognosis of patients is relatively poor. The age, pathological type and TNM staging are closely related to the prognosis of patients. Preoperative blood PLR may play a role in the prediction of prognosis, but preoperative blood NLR is not related with the prognosis of patients.</p>

Impact of lymph node metastasis on survival of patients with pancreatic cancer / 中华肝胆外科杂志

Objective To study the impact of lymph node metastasis on prognosis of patients with pancreatic cancer and to evaluate predictors of postoperative survival of these patients.Methods The clinical data on patients with pancreatic cancer who underwent pancreatic cancer radical surgery in our hospital from January 2002 to December 2013 were reviewed and analyzed.Data on lymph node metastasis,number of lymph node dissection,number of positive lymph nodes and positive lymph ratio were analyzed.Results Of 101 patients,the 6-month,1-year and 2-year survival rates were 84.2％,56.6％ and 28.5％,respectively.The median survival was 13.8 months.Univariate and multivariate analyses showed lymph node metastasis,a positive lymph node ratio,number of lymph node dissection and positive lymph nodes were independent influential factors of prognosis.Results of subgroup analysis showed the number of lymph node dissection was a prognostic factor for pNO patients,while a positive lymph ratio had no impact on survival of pN1 patients.In the subgroup of patients with pancreatic head cancer,lymph node metastasis was associated with prognosis but not in the subgroup of patients with pancreatic body and tail carcinoma.Conclusions For patients with pancreatic head cancer,lymph node metastasis was closely correlated with prognosis.In addition,factors including lymph node metastasis,number of lymph node dissection,a positive lymph node ratio and number of positive lymph nodes were independent influential factors of prognosis for patients with pancreatic head cancer.However,for pN1 patients,a positive lymph node ratio has no influence on prognosis.

Risk factors of pancreatic fistula after pancreaticoduodenectomy / 中华胰腺病杂志

Objective To analyze the risk factors of pancreatic fistula after pancreaticoduodenectomy,in order to provide evidence to reduce post-operative complication in clinical practice.Methods The clinical data of 352 patients with malignancy who received pancreaticoduodenectomy at the Shanghai Renji Hospital from September 2009 to September 2012 were retrospectively analyzed.The patients were divided into pancreatic fistula group and non-pancreatic fistula group.Peri-operative risk factors of pancreatic fistula after pancreaticoduodenectomy were analyzed by univariate and multivariate logistic regression analysis.Results Forty-nine cases of pancreatic fistula occurred,and the incidence rate of pancreatic fistula was 13.9％ (49/352).Univariate and multivariate logistic regression analysis showed sex,age,history of diabetes,operation time,intra-operative blood loss,vessel reconstruction,pancreatic tube placement,anastomosis time,type of digestive tract reconstruction were not risk factors of pancreatic fistula; however,brittle pancreatic tissue,diameter of pancreatic duct ＜3 mm,pre-operative total bilirubin level ＞ 171 μmol/l,duration of preoperative jaundice ＞ 8 weeks,pre-operative albumin level ＜30 g/L were the independent risk factors of pancreatic fistula (P ＜ 0.05).Conclusions Brittle pancreatic tissue,small pancreatic duct,high level of serum bilirubin,long duration of preoperative jaundice,low level of serum albumin are the independent risk factors of pancreatic fistula after pancreaticoduodenectomy.

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>

Choices of different pancreaticojejunostomies in patients after pancreaticoduodenectomy / 中华普通外科杂志

Objective To evaluate the pancreaticojejunostomy procedures selection strategy after pancreaticoduodenectomy.Methods The clinical data of 305 cases who received pancreaticoduodenetomy at Shanghai Renji Hospital from Jan 2010 to Jan 2013 were retrospectively analyzed.For patients with pancreatic duct diameter≥3 mm,duct-to-mucosa pancreaticojejunostomy was applied(120 cases).For duct diameter ＜ 3 mm,modified Child pancreaticojejunostomy was applied to 80 cases when pancreatic stump was large,or binding pancreaticojejunostomy procedures was applied to 105 cases while pancreatic stump was small.Results The diameter of the pancreatic stump in modified Child group was significantly larger than that in the binding group (F =5.78,P ＜ 0.05).The overall incidence of pancreatic fistula was 11.1％ (34/305).There were no significant differences in the incidences of pancreatic fistula,peritoneal bleeding,abdominal infection,digestive dysfunction rate,the mean duration of hospital and the death cases among the three groups (x2 =1.51,2.78,1.16,3.75,1.94,F=2.13,P＞0.05).Conclusions Three different pancreaticojejunostomies based on the size of pancreatic duct and pancreatic stump are equally safe and effective as a reconstructive method after pancreaticoduodenectomy.

Analysis and treatment of intra-abdominal infectious after pancreatic surgery / 中华肝胆外科杂志

Objective To study the bacterial types and their drug resistance in intra-abdominal infections after pancreatic surgery,and to evaluate the appropriate treatment measures.Methods 113 patients who underwent pancreatic surgery from Jan 2012 to Dec 2012 in our hospital were included into this study.The drainage liquid from the surgical sites were collected for bacterial culture and drug susceptibility tests.Results The incidence of intra-abdominal infections was 39.8％ (45/113).There were 54 pathogenic strains of bacteria isolated,including 49 strains of gram-negative bacteria (90.7％),4 strains of gram-positive bacteria (7.4％),and 1 strain of fungus (1.9％).The top three pathogens were Pseudomonas aeruginosa (50.0％),Acinetobacter baumannii (14.8％) and Singular deformation bacteria (1 1.1％).Most gram-negative bacteria were sensitive to Polymyxin B and Aminoglycoside antibiotics (＞ 70％),but they were resistant to Imipenem and Cephalosporin which were commonly administered.Pancreatic fistula was closely related to intra-abdominal infections.Concluusions A gram-negative bacteria,Pseudomonas aeruginosa,was the predominant organism in intra-abdominal infections after pancreatic surgery in our hospital.The situation of drug-resistance was still severe.More effective measures should be taken to prevent growth of resistant strains such as using antibiotics according to drug sensitivity and avoiding empirical single use of broad-spectrum antibiotics.Pancreatic fistula commonly led to intra-abdominal infections.

CT-guided Percutaneous Minimally Invasive Treatment by Using Herbert Screws for Wrist Scaphoid Fracture:Report of 21 Cases / 中国微创外科杂志

Objective To investigate therapeutic effects of CT-guided percutaneous minimally invasive treatment by using Herbert screws for wrist scaphoid fracture . Methods From September 2010 to October 2012, 21 patients with scaphoid fracture were treated by internal fixation by using Herbert screws under the guidance of CT .The results of the procedure were assessed in terms of osseous union , pain extent , grip strength , and active motion of the wrist .Postoperative outcomes were evaluated by wrist standard scores based on patients’ perception of functions. Results The operation time was 25 -55 min (mean, 35.3 min).The intraoperative blood loss was 8-40 ml (mean, 18.6 ml).Fracture fragments were cured with bone union , with an average healing time of 10.4 weeks (range, 8-17 weeks).All the 21 cases were followed up for 8 -13 months (mean, 9.8 months).The VAS scores at the last follow-up was (1.2 ±0.8) points, which was significantly lower than that before the operation (5.3 ±1.4) points (t=11.785, P=0.000).The grip strength was (39.6 ±3.5) kg, which was significantly higher than that preoperatively [(19.4 ± 2.4) kg, t=-21.624, P =0.000].The Angle of wrist flexion and extension was 115.2°±7.4°, significantly higher than preoperative measure (89.8°±10.4°, t =-9.103, P =0.000).The wrist ulnar radial deflection angle was 53.7°±5.5°, significantly higher than preoperative one (39.4°±3.4°, t =-10.116, P=0.000).At the last follow-up assessment of wrist functions, excellent result was recorded in 18 cases, and good in 3 cases, with a good-or-excellent rate of 100%. Conclusion Treatment of scaphoid fracture with Herbert screws under the guidance of CT is a minimally invasive method , bearing advantages of little incision, simple operation performance , and good effects .

Pancreatic fistula after distal pancreatectomy / 中华普通外科杂志

Objective To evaluate measures in the prevention of pancreatic fistula after distal pancreatectomy.Methods Clinical data of 124 cases of distal pancreatectomy performed during 2000 and 2009 in our hospital were retrospectively analyzed,including 86 cases of pancreatic carcinoma,12 cases of pancreatic pseudocyst and pancreatic benign tumor,18 cases of gastroenteric tumor with pancreatic body/tail invasion,3 cases of chronic pancreatitis with body/tail pseudocyst,5 cases of pancreatic injury.Cases were divided into two groups retrospectively by ways the stump pancreas were closed.Group A included 63 cases in which the stump end was closed by simple interrupted mattress suture,group B including 61 cases in those the stump was sutured by interrupted mattress combined with a safe ligation of the main pancreatic duct.Results Pancreatic fistula occurred in 22 cases in group A,the incidence was 34.9％,among the 22 cases,10 cases were high-flow type,12 cases were low-flow type; while the pancreatic fistula occurred in 9 cases in group B,the incidence was 14.7％,there was no high-flow type fistula.Conclusions Interrupted mattress suture combined with interlocking suture and suture of main pancreatic duct is effective in decreasing the rate of pancreatic fistula after distal pancreatectomy.

Effects of DDR2 siRNA on carbon tetrachloride-induced liver fibrosis in rats / 中华肝胆外科杂志

Objective To explore the effects of silencing DDR2 expression by siRNA on CCl4-induced liver fibrosis and its mechanism in rats. Methods Liver fibrosis model was induced by intraperitoneal injection of CCl4 twice a week for 6 consecutive weeks. Some rats were administered siRNA targeting DDR2 (0. 3 mg/kg), saline or control siRNA every three days from the beginning of CCl4 injection via tail vein injection, while other rats were treated in the same pattern after 2-week CCl4 injection. Quantitative real-time polymerase chain reaction (QRT-PCR) and Western blot were used to detect the mRNA and protein expressions of DDR2, MMP-2 and COL Ⅰ . Meanwhile, the pathological changes of liver tissues and the levels of liver function were also observed. Results QRT-PCR showed that the DDR2, MMP-2 and COL Ⅰ mRNA in the chemically synthetic cholesterol-modified siRNADDR2 group were significantly decreased as compared with those in the control group (P＜0.01) ,and the protein expressions of DDR2, MMP-2 and COL Ⅰ were also significantly decreased (P＜0. 01,4 wand 6w). In addition, in comparison with those in the control group, the pathological changes of liver tissues in the siRNA-DDR2 treated group were markedly attenuated, and the levels of ALT(1356.17 ±83.80 nkat/L vs 2532. 70±145.11 nkat/L,4w,1367. 60±321.76 nkat/L vs 2604.37±255.02 nkat/L,6w,P＜0. 01 ) and AST (2460. 80 ± 207. 58 nkat/L vs 3983. 70 ± 253. 08 nkat/L, 4w, P＜ 0. 01,2383.27±290.16 nkat/L vs 3227.70±353. 34 nkat/L,6w,P＜0. 05)were also significantly lowered,while the level of TBIL (7. 97 ± 1.60 μmol/L vs 3.80± 0.60 μmol/L, 4w, 10.40±1.61 μmol/L vs 6.10±0.79 μmol/L,6w,P＜0. 01)was markedly increased. Conclusion Systemic administration of cholesterol-modified siRNA targeting DDR2 could significantly suppress the expression of DDR2, decrease the contents of the extracellular matrix,and thus has a potential antifibrotic effect.

Management of perioperative ascites in cirrhotic patients undergoing abdominal operation / 中华普通外科杂志

Objective To discuss the perioperative management of cirrhotic patients undergoing abdominal operation. Methods From Jan. 2000 to Jul. 2007, 93 patients with PHT underwent operation in our hospital. We retrospectively analyzed the data according to different therapy result. Results 21 cases developed postoperative ascites. The occurrence of ascites in patients dealt with PHT and coexistent other abdominal disease was 7% and 12% respectively for Child A and B grade patients. The occurrence of ascites in patients dealt with only abdominal disease was 13% and 17% respectively for Child A and B grade patients. The occurrence of ascites in patients dealt with PHT and abdominal disease was amazingly 83% for Child C cases. Patients suffered from tumors didn't have more risk of ascites than the other patients. Conclusion The proper perioperative management of patients can decrease the mortality. To deal with PHT together with abdominal operation is reasonable for patients in Child A or B liver function, and it would not increase the postoperative ascites. For the selective patients, we must try our best to decrease the ascites preoperatively to improve the condition.

Effects of siRNA targeting DDR2 on hepatic stellate cells / 中华普通外科杂志

Objective To explore the effects of inhibiting DDR2 expression by siRNA on hepatic stellate cells and evaluate the role of DDR2 gene in hepatic fibrogenesis. Methods (1) Three pairs of chemically synthesized siRNAs targeting DDR2 were respectively transfected into HSC-T6 cells for evaluation of silence efficacy, and the most effective siRNA was used. (2) HSC-T6 cells were divided into three groups, group A served as normal controls, group B served as negative control and group C was RNA interference DDR2 (siRNA-DDR2) expression of HSC. The most effective RNA interference sequences targeting DDR2 gene was chosen to transfect HSC-T6 cells by plasmid transfection. The tendency of DDR2, α-smooth muscle actin(α-SMA) and collagen-Ⅰ mRNA expression were estimated using RT-PCR, and the protein expression of DDR2 was evaluated by Western blot. Meanwhile, MTT assay was employed to analyze the proliferation of HSC. Results (1) DDR2 siRNA, which began at nt 868, inhibited DDR2 gone expression stronger than the other two siRNAs. (2) After transfection of siRNA-DDR2, the mRNA expression of DDR2 (P<0.01) and α-SMA (P<0.01) significantly decreased compared with the normal group, and the protein expression of DDR2 also significantly decreased (P<0.01). In addition, the proliferation of HSC was also markedly suppressed as compared with the normal group (P<0.01). However, compared with the negative control group, none of them was markedly suppressed. Conclusion SiRNA targeting DDR2 significantly suppresses the activation, proliferation of HSC, and thus attenuates hepatic fibrogonesis in vitro.

High-frequency electrocautery in the treatment of massive hemorrhage of presacral venous plexus / 中华消化外科杂志

Objective To assess the clinical value of high-frequency electrocautery in the treatment of massive hemorrhage of presacral venous plexus. Methods The clinical data of 8 patients with presacral venous hemorrhage treated with high-frequency electrocautery from February 2005 to March 2008 were analyzed. Once the presacral venous hemorrhage happened, the bleeding site was pressed with a gauze or finger and the accumulated blood was aspirated. Then, while simultaneously withdrawing the gauze or finger over the bleeding sites, high-frequency electrocautery was applied with a power of 80-100 W to coagulate all the bleeding sites. Results High-frequency electrocautery was used to stop bleeding in the 8 patients, and no electrocautery related complica-tions occurred postoperatively. Conclusions High-frequency electrocautery for massive hemorrhage of presacral venous plexus is simple, efficient and safe.

Diagnosis and treatment of primary retroperitoneal tumor in 71 cases / 中国普通外科杂志

Objective To investigate the preopera ti ve diagnosis and the surgical treatment of primary retroperitoneal tumor(PRT). Methods The clinical dat a of 71 patients with PRT were retrospectively analyzed including clinical manif estation, radiologic studies, pathologic examination and surgical procedures. Results There were 32 cases of benign tumor, 38 cases of malignant tumor and 1 case of borderline tumor. Of the 32 patients with benign tumor, 31 underwent complete surgical resection. Of the 38 patients with malignant tumor, 29 underwent complete resection. One patie nt with borderline tumor underwent total resection. The 5-year survival rate of benign PRT was 89.29%, the 5-year survival rate of malignant PRT was 20.80%. Four cases of recurrent benign PRT underwent complete resection. Ten cases of r ecurrent malignant PRT underwent complete resection and 3 underwent partial rese ction. ConclusionsRadiolog ical study is crucial for the diagnosis. Complete resection is the key for the t reatment of PRT.

A study on the mechanism of altered gastrointestinal motility in portal hypertensive rats / 中国普通外科杂志

Objective To evaluate the mechanism of altered gastrointestinal motility in portal hypertensive rats. Methods Thirty-two male Sprague-Dawley rats were divided into four groups:sham- operation control (SO, n=8), prehepatic portal hypertension by partial stenosis of the portal vein (PHPH, n=8 ), intrahepatic portal hypertension induced by injection of CCl 4 (IHPH, n=8), and intrahepatic portal hypertension with portacaval shunt (IHPH-PCS, n=8). Gastrointestinal myoelectrical activity and motility were monitored. Gastrointestinal hormones were measured with radioimmunoassay.Results Compared with SO rats, gastrointestinal motor index(MI) were reduced and abnormal myoelectrical activity were recorded (P