Locally advanced undifferentiated carcinoma with osteoclast-like giant cells of the pancreas.

Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas (UCOGCP) is an unusual pancreatic neoplasm that represents < 1% of all pancreatic malignancies. Moreover, the giant cells of UCOGCP morphologically resemble the benign giant cells of bone tumors. Due to the rarity of this tumor type, the histogenesis and biologic behavior of UCOGCP remain controversial. Here, we report a case of UCOGCP that exhibited an invasive growth pattern involving infiltration of the adjacent bowel loop and portal vein, as well as superior mesenteric vein thrombosis. The patient underwent a distal pancreatectomy with splenectomy and partial colectomy, followed by four cycles of gemcitabine chemotherapy. No evidence of recurrence was detected after ten years. In addition to this case, clinical information on other UCOGCP cases reported in the English literature is summarized.

[The diagnosis and management strategies for gastrointestinal hemorrhage following pancreaticoduodenectomy].

OBJECTIVE: To analyze the causes and clinical features of gastrointestinal hemorrhage following pancreaticoduodenectomy (PD), and to provide the management strategies for this complication. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Secreted protein acidic and rich in cysteine (SPARC) suppresses angiogenesis by down-regulating the expression of VEGF and MMP-7 in gastric cancer.

BACKGROUND: Secreted protein acidic and rich in cysteine (SPARC) is a glycoprotein that functions to inhibit angiogenesis, proliferation, and invasion in different types of cancer. The ability of SPARC to modulate neovascularisation is believed to be mediated in part by its ability to modulate the expression of vascular endothelial growth factor (VEGF) and matrix metalloproteinases (MMPs). In this study, we aimed to determine the effect of SPARC expression in gastric cancer cells on proliferation and angiogenesis in vitro and in vivo. METHOD: We evaluated expression of SPARC in seven human gastric cancer cell lines. Then we established a stably transfected SPARC overexpressed cell line (BGC-SP) and a stably transfected SPARC knock-down cell line (HGC-sh). The effect of SPARC overexpression and SPARC silencing was studied by examining capillary formation of HUVECs in vitro and a dorsal skin-fold chamber model in vivo. Quantitative real-time PCR and western blotting were performed to detect if the expressions of VEGF and MMP-7 were modulated by SPARC expression. To further determine the effect of SPARC expression on angiogenesis in vivo, xenograft models were established and microvessel density (MVD) of different clones were detected by immunohistochemistry. RESULTS: Endogenous SPARC overexpression inhibited the expression of VEGF and MMP-7, as well as the angiogenesis induced by BGC-SP cells. Correspondingly, SPARC silencing increased the expression of VEGF and MMP-7, as well as the angiogenesis induced by HGC-sh cells. Elevated angiogenesis induced by SPARC silencing in HGC-sh cells was decreased when VEGF was neutralised by antibodies, and MMP-7 was knocked down in vitro. CONCLUSION: SPARC suppresses angiogenesis of gastric cancer by down-regulating the expression of VEGF and MMP-7.

Influential factors and effect evaluation of the intra-operative puncture biopsy for pancreatic masses.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

[Surgical complications after pancreatoduodenectomy: risk factors and treatments].

OBJECTIVE: To explore the impact factors and treatment of post pancreatoduodenectomy complications. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

[The diagnosis and surgical management for patients with variants of hepatic arteries in the procedure of pancreaticoduodenectomy].

OBJECTIVE: To study the principle and surgical managements for the patients with anatomic variants of hepatic artery in the procedure of pancreaticoduodenectomy (PD). METHODS: 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. RESULTS: 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. CONCLUSIONS: Performing CT scan preoperatively, especially CTA,is effective to diagnose these disorders. Skillful surgical techniques can manage the anatomic variants safely.

[Influencing factor analysis of delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy].

OBJECTIVE: To investigate the influencing factors of delayed gastric emptying (DGE) after pylorus-preserving pancreaticoduodenectomy (PPPD) and its preventing managements. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

[Genotype of extended-spectrum beta-lactamases produced by antibiotic-resistant Escherichia coli and Klebsiella pneumoniae in surgical intensive care unit].

OBJECTIVE: To describe the antibiotic resistant mode of extended-spectrum beta-lactamases(ESBLs) producing Escherichia coli (E. coli.) and Klebsiella pneumoniae (KPn) in surgical intensive care unit(SICU), and to implore the molecular epidemiology of ESBLs coding genes of these strains. METHODS: The minimal inhibitory concentrations (MICs) at antibiotics were examined by agar dilution method. The ESBLs coding genes were amplified by TEM, SHV and CTX-M specific primers. Amplicons of such genes with conjugates' plasmids as templates were sequenced. RESULTS: In vitro susceptibility tests of ESBLs producing strains showed a high level of resistance to most of the beta-lactam biotics, especially cefotaxime. 93.5% of these ESBLs positive strains contained CTX-M group genes,and 38.7% of the strains contained SHV genes. By sequencing, some genotype were determined: TEM-1, CTX-M-1,3,14,22. CONCLUSION: ESBLs producing strains were resistant to most of the beta-lactam biotics. The most prevalent ESBLs genotype of ESBLs produced by E coli and KPn in SICU was CTX-M subgroup. The most probable reason might be the extensive use of cefotaxime.