整块切除是局限性胰腺癌的治疗方法之一。切除相关围手术期病死率低，但在某些高风险患者中其并发症发生率高达50%。随着围手术期治疗护理水平的提高，包括毗邻血管的可获得阴性切缘的根治性切除已在大型医院里实施，早前在胰腺手术中使用微创技术的结果表明其应用前景良好。最新的关于如何降低胰腺相关手术围手术期并发症的数据，在此也将得到讨论。

Objective: To assess the clinical efficacy of the pylorus preserving pancreaticoduodenectomy (PPPD) and pancreaticoduodenectomy (PD) for carcinoma of the periampullary region and pancreatic head by means of systematic review. Methods: The studies both at home and abroad concerning PPPD versus PD for carcinoma of the periampullary region and pancreatic head were thoroughly searched. The quality of included studies was assessed according to the Cochrane systematic review method and statistical analysis of data was performed using RevMan 5.0 software. Results: Six randomized controlled studies were included, with a total of 468 patients, of whom, 232 cases underwent PPPD and 236 cases underwent PD. The results of Meta-analysis indicated that there were no significant differences between the two groups in 1-, 2- and 3-year survival rate (RR=1.20, 95% CI=0.73–1.97; RR=1.02, 95% CI=0.78–1.32; RR=0.99, 95% CI=0.84–1.16), and incidence of postoperative complications and delayed gastric emptying (RR=0.86, 95% CI=0.66–1.14; RR=1.30, 95% CI=0.69–2.45) (all P>0.05). The intraoperative blood loss and operative time in PPPD group were significantly reduced compared with PD group (WMD=–527.21, 95% CI=–1044.05––10.36, P=0.05; WMD=–29.82, 95% CI=–48.05––11.59, P=0.001). Conclusion: Compared with PD, PPPD does not increase the incidence of postoperative complications, and furthermore, it reduces the intraoperative blood loss and operative time on the basis of appropriate indications

Objective: To evaluate the reliability of using POSSUM scoring system for risk estimation in elderly patients undergoing pancreaticoduodenectomy (PD). Methods: Eighty patients undergoing PD between February 2011 and February 2010 were divided into two groups according to their ages. Of the patients, 38 cases ≥80 year old were allocated to observational group, and the other 42 cases >80 years old served as control group. The intra- and postoperative conditions of the two groups of patients were analyzed, and the POSSUM scores between the two groups as well as the difference between the POSSUM predicted and actual incidence of complications and mortality in the two groups were compared. Results: In observational group, the operative time, intraoperative blood loss and blood infusion requirement showed no significant difference versus control group (all P>0.05), but length of hospital stay was longer than that of control group (P<0.05). The POSSUM score in observational group was significantly higher than that in the control group (P<0.05); there was no significant difference between the predicted and actual incidence of complications and mortality in observational group (P>0.05), but both actual incidence of complications and mortality were significantly lower than those of predicted values in control group (P<0.05). Conclusion: Application of POSSUM scoring system can provide a relatively accurate estimation of the surgical risk in elderly patients undergoing PD, so it has guiding significance for these patients in perioperative management.

Objective: To assess the clinical value of the dissection of lymph nodes along the superior mesenteric artery (SMA) (14th group) and cytokeratin (CK) staining of resected lymph nodes in patients with pancreatic head carcinoma. Methods: The clinical data of 24 patients undergoing pancreaticoduodenectomy (PD) alone (PD group) and 32 patients undergoing PD plus dissection of lymph nodes along the SMA (PD+SMA clearance group) for pancreatic head cancer were analyzed. The perioperative conditions and postoperative survival rates between the two groups were compared, and the detection rates for lymphatic micrometastasis between routine pathological examination and CK immunohistochemical staining were also compared. Results: Comparing PD group versus PD+SMA clearance group, there were no significant differences in operative time [(4.5±1.03) h vs. (5.0±1.25) h], intraoperative blood loss [(1 462.5±911.73) mL vs. (1 687.5± 1 522.63) mL], length of postoperative hospital stay [(16.13±3.09) d vs. (18.25±7.17) d], or incidence of postoperative complications (8.3% vs. 9.4%) (all P>0.05). The 3-year survival rate in PD+SMA clearance group was significantly higher than that of PD group (P=0.044). The positive rate of lymph node metastasis was 6.25% (2/32) by routine pathological examination, which was increased to 21.88% (7/32) by detection of CK immunohistochemical staining. Conclusion: There is a relatively high incidence of lymphatic micrometastasis along the SMA in pancreatic head cancer patients, and CK determination can raise the detection rate of lymphatic micrometastasis. PD plus skeletonized dissection of the SMA does not increase the surgical risk or incidence of postoperative complications, and furthermore, it may improve the prognosis of pancreatic head cancer patients.

Objective: To compare the clinical efficacy of the different pancreatico-enteric anastomosis procedures after pancreaticoduodenectomy (PD). Methods: The clinical data of 260 patients undergoing PD from March 2008 to March 2013 were retrospectively analyzed. The patients with pancreatic duct diameter ≥4 cm underwent duct-to-mucosa pancreaticojejunostomy (135 cases); of the patients with pancreatic duct diameter <4 cm, the cases with jejunal lumen less than the size of pancreatic stump underwent modified Child pancreaticojejunostomy (67 cases), while the cases with jejunal lumen equal or greater than the size of pancreatic stump underwent binding pancreaticojejunostomy (58 cases). The clinical efficacy and incidence of postoperative complications among the three groups were compared. Results: The operations were completed in all patients. The incidence of postoperative complications such as pancreatic juice leakage, abdominal infection, intra-abdominal hemorrhage and digestive dysfunction as well as the average length of hospital stay among the three groups showed no statistical difference (all P>0.05). One elderly patient died of cerebrovascular accident on the fourth day after operation, and the remaining patients were followed up for 3.2 (2–4) months, during which time no recurrence, metastasis or death occurred. Conclusion: The procedure of post-PD pancreatico-enteric anastomosis should be selected according to the pancreatic duct diameter and size of the pancreatic stump as well as the size of the jejunal lumen. The proper post-PD pancreatico-enteric anastomosis could yield favorable results.

Objective: To evaluate the value of percutaneous transhepatic gallbladder drainage (PTGD) in high-risk patients prior to undergoing pancreaticoduodenectomy (PD). Methods: The clinical data of 15 patients with pancreatic head or periampullary cancer who had high risk factors and treated from January 2008 to December 2012 were retrospectively analyzed. All these patients received PTGD to improve their general condition prior to undergoing PD procedure. Results: PTGD was carried out successfully in all 15 patients with no occurrence of complications such as bile leakage, pneumothorax or internal bleeding. Drainage tubes in all patients remained patent with a daily drainage volume of 800 to 2 500 mL. Jaundice reduction effect was satisfactory, and the serum bilirubin concentration in all patients was less than 200 μmol/L after drainage for 10 to14 d. Subsequently, PD procedure was performed successfully in all patients. No serious postoperative complications occurred in any patient of the entire group, and all patients recovered. Conclusion: For patients with pancreatic head or periampullary cancer who have high-risk factors such as severe jaundice, severe biliary infection, severe medical problems or malnutrition, the use of PTGD prior to PD can reduce the incidence of postoperative complications and increase surgical safety.

Objective: To compare the clinical efficacy of different modalities for treatment of pancreatic cancer. Methods: The clinical data of 100 patients with pancreatic cancer admitted from January 2008 to February 2011 were analyzed. Of the patients, 30 cases underwent surgical resection alone (surgical treatment group), 30 cases received chemotherapy alone (chemotherapy group), 30 cases underwent surgical resection plus chemotherapy (combination treatment group) and the remaining 10 cases received other treatment (other treatment group). The survival status and adverse reactions after treatment among the groups were compared. Results: The median survival time of patients after treatment in surgical treatment group, chemotherapy group, combination treatment group and other treatment group was (13.77±1.44), (11.95±1.60), (17.26±1.44) and (2.89±1.46) months respectively, and the survival status of combination treatment group was significantly better than that of the other three groups (χ2=45.96, P=0.000). The overall incidence of adverse reaction in combination treatment group (3.33%) was significantly lower than that in surgical treatment group (26.67%), chemotherapy group (30.00%) and other treatment group (30.00%) (χ2=8.178, P=0.04). Conclusion: For pancreatic cancer patients, treatment approaches should vary according to the individual clinical circumstances, but the surgery-based multimodality treatment remains the most effective method.

Objective: To investigate the diagnosis and treatment of insulinoma. Methods: The clinical data of 22 patients with insulinoma admitted from 2008 to 2013 were retrospectively analyzed. Results: Of the patients, the lesion in 21 cases (95.5%) was benign, and only in one case (4.5%) was malignant. All patients had various degrees of the symptoms of Whipple’s triad, and 4 cases had different types of neuropsychiatric symptoms. The measurement of fasting serum insulin was performed in 15 patients, in all of whom the insulin release index was higher than 0.3. The preoperative tumor detection by B-type ultrasound scan, CT examination, MRI and somatostatin receptor scintigraphy was 22.7% (5/22), 54.5% (12/22), 53.8% (7/13) and 100% (1/1), and the detection rate of intraoperative B-ultrasound (IOUS) examination was 100% (10/10), respectively. Tumor enucleation was performed in 18 patients, 2 patients underwent pancreatic body and tail resection and 2 patients received pancreatic body and tail resection plus splenectomy. After surgery, the blood sugar levels in 21 patients returned to normal, but one case showed persistent hypoglycemic symptoms due to a missed tumor located in the uncinate process of the pancreas which was found by a second surgical exploration done three months later, and then the patient became normoglycemia after tumor resection. The neuropsychiatric symptoms persisted in one patient. Pancreatic fistula occurred in one case, which was completely cured three weeks later by adequate drainage and inhibition of pancreatic secretion. Conclusion: Whipple's triad and insulin release index higher than 0.3 are the mainstay for the etiologic diagnosis of insulinoma, and preoperative CT and/or MRI plus surgical exploration and intraoperative ultrasound are sensitive for lesion localization. Surgical removal is the conventional treatment for this condition.

Objective: To investigate the diagnosis, treatment and prognosis of glucagonoma with liver metastasis. Methods: The two hospitalization records of one glucagonoma patient with liver metastasis were reviewed. Based on the patient’s surgical history of distal pancreatectomy plus splenectomy, the treatment modality and results of this condition were analyzed. Results: After confirmation by laboratory and imaging examinations, this case of metastatic glucagonoma to the liver underwent right posterior lobectomy and regional resection of the tumor in the left lobe plus cholecystectomy by using ultrasound knife, and was discharged after improvement. The patient recovered well during the one-month follow-up period. Conclusion: Liver metastasis may occur in glucagonoma after surgery. Surgical removal is the effective treatment option for this condition with better prognosis. Liver transplantation may be considered when necessary.

Objective: To investigate the influence of wogonin on the growth of pancreatic cancer Panc-1 cells in vitro and in vivo. Methods: Panc-1 cells were exposed to different concentrations (1, 10 and 100 μmol/L) of wogonin for 24 h, and the cell proliferation and apoptosis were determined by MTT assay and flow cytometry. Twenty nude mice bearing Panc-1 cell xenografts were equally randomized into control group, wogonin treatment group (wogonin 60 mg/kg, daily), gemcitabine treatment group (gemcitabine 150 mg/kg, weekly) and combination treatment group (wogonin plus gemcitabine). After 2 consecutive weeks of treatment and 7 d discontinuation, the growth statuses of the tumor xenografts among groups were compared, and the microvessel density (MVD) and expression of vascular endothelial growth factor (VEGF) in the tumor tissues were detected by immunohistochemical staining. Results: Compared with untreated control cells, the OD values were decreased and apoptotic rates were increased significantly in Panc-1 cells treated with any of the 3 concentrations of wogonin, and both effects presented a concentration-dependent manner (all P<0.05). Compared with control group of mice, the tumor graft growth in mice of wogonin treatment group, gemcitabine treatment group and combination treatment group were all remarkably suppressed, and the tumor suppression rate was 24.8%, 30.5% and 66.1% respectively, which was significantly higher in combination treatment group than that in either of the single-drug treatment groups (both P<0.05), but showed no statistical difference between the two single-drug treatment groups (P>0.05); the intratumoral CD31 (reflecting MVD) and VEGF expressions in all three treatment groups were significantly reduced with the degrees tending to be more evident in order of gemcitabine treatment group, wogonin group and combination treatment group, and the difference between any two groups had a statistical significance (all P<0.05). Conclusion: Wogonin can inhibit proliferation and induce apoptosis in pancreatic cancer cells in vitro; in a certain degree, it can suppress the growth of pancreatic cancer in vivo and enhance the sensitivity of pancreatic cancer to chemotherapy drugs which may be associated with its action of reducing tumor angiogenesis.

Objective: To detect the sodium-independent equilibrative nucleoside transporter (ENT) and sodium-dependent concentrative nucleoside transporter (CNT) on pancreatic cancer cell membrane and make a quantitative assessment of ENT. Methods: Pancreatic cancer cell line (Panc-1) was incubated in the medium containing dipyridamole (100 μmol/L) for 8, 15, 60 and 120 min, respectively. Afterwards, the cells were harvested and lysed with acetonitrile, the fluorescence intensity of dipyridamole in the cell suspension was detected by spectrofluorometer, and the sum of ENTs on a single cell was calculated according to the number of the cells in the parallel suspension. Next, Panc-1 cells were incubated in the medium containing 5-fluorouracil (5-FU) or 5-FU plus dipyridamole for 15, 30, 60, 120 and 240 min, respectively, and the content of 5-FU in the cell was measured by capillary zone electrophoresis; the 5-FU concentration in a single cell was counted according to the number of cells and the single cell volume in the parallel suspension to indirectly determine whether CNT was present on the cell membrane of Panc-1. Results: The fluorescence was detected in Panc-1 after 8 min of incubation in the medium containing dipyridamole with a maximal level of 20.2×10–19 mol at 15 min. The sum of ENTs was determined at 1.25×105 in a single cell according to the dipyridamole content. 5-FU was still transported into the Panc-1 cells after the blockage of ENT with dipyridamole and the maximal level of intracellular 5-FU reached (138.3±9.77) mg/L, which was significantly higher than that of the medium (P=0.011). Conclusion: ENTs on the cell surface can be quantitatively determined through fluorescence intensity detection after their binding with dipyridamole. Whether CNT is present on the cell membrane can be determined by measuring the intracellular 5-FU concentration after the blockage of ENT, and therefore provides a reference for the rational use of chemotherapeutic drugs and improvement of their effect.

Objective: To investigate the alteration in heme oxygenase 1 (HO-1) activity in lung tissues from rats with severe acute pancreatitis (SAP) and its significance, as well as the influence of ulinastatin intervention. Methods: Rats were randomly divided into normal control group, SAP model group, HO-1 inducer treatment group and ulinastatin treatment group. Rats in the latter 3 group underwent retrograde cholangiopancreatic duct injection of 5% sodium taurocholate to elicit SAP model, and then rats in HO-1 inducer treatment group and ulinastatin treatment group were intravenously injected with bovine hemin or ulinastatin at 5 min after SAP model induction respectively, while those in SAP model group were injected with normal saline instead. On different time points after operation, in each group of rats, the pathological changes in the lung tissues were assessed, and the wet-to-dry lung weight ratio as well as the myeloperoxidase (MPO) activity and HO-1 expression in the lung tissues were determined. Results: Except in the normal control group, rats in all other groups exhibited obvious lung injury, which in the two treatment groups was obviously milder than that in SAP model group. Compared with normal control group, the wet-to-dry lung weight ratio, and pulmonary MPO activity and HO-1 expression in all the remaining groups were significantly elevated (all P<0.05), with a basically time increasing trend. Compared with SAP model group, the wet-to-dry lung weight ratios and pulmonary MPO activities were significantly decreased, while lung HO-1 expressions were significantly increased in the two treatment groups (all P<0.05). No statistical difference was noted in any of the parameters between the two treatment groups (all P>0.05). The correlation analysis revealed that there was a significant correlationship between HO-1 expression in the lung tissue and pulmonary MPO activity or wet-to-dry lung weight ratio in SAP rats (r=–0.79 and –0.77, both P<0.05). Conclusion: HO-1 activity is increased in rat lung tissue during SAP, and its enhancement through using HO-1 inducer can alleviate the SAP-induced acute lung injury. The protective effect of ulinastatin against SAP-induced acute lung injury may be partially associated with promotion of HO-1 activity.

Objective: To investigate the therapeutic effect of TDZD-8 (4-benzyl-2-methyl-1, 2, 4-thiadiazolidine-3, 5-dione) on acute pancreatitis in mice. Methods: Fifty-four BALB/c mice were equally randomized into control group, model group and treatment group. The mice in model group and treatment group were subjected to intraperitoneal injection of caerulein (50 μg/kg per hour, 13 times) to induce AP, while the mice in control group were treated with normal saline of the same volume in the same fashion, and mice in treatment group were intraperitoneally injected with 10 mg/kg TDZD-8 at 30 min after the last caerulein injection. At 3, 6 and 12 h after the last caerulein injection, 6 mice at each time point in each group were sacrificed. Then, the blood levels of amylase and interleukin 6 (IL-6) were measured, the pancreatic pathology was assessed by HE staining and nuclear factor κB (NF-κB) expression in the pancreatic tissue was determined by immunohistochemical staining. Results: Compared with control group, in model group and treatment group, the blood levels of amylase and IL-6, and pathological scores and NF-κB expressions in pancreatic tissues were all markedly increased, and were gradually increased with time prolongation, while all values of above parameters in treatment group were lower than those in model group; all the differences reached statistical significance (all P<0.05). Conclusion: TDZD-8 has protective effect against acute pancreatitis in mice, and the mechanism is probably associated with its inhibition of NF-κB activity and thereby attenuate the inflammatory response.

Objective: To study the expression and significance of apoA-I binding protein (AIBP) in hepatocellular carcinoma (HCC) cells. Methods: The mRNA and protein expressions in normal hepatic L02 cells, AFP-positive HCC HepG2 and Hep3B cells, and AFP-negative HCC SMMC7721 cells were measured by RT-PCR and Western blot, respectively. The recombinant vector pcDNA3.1-AFP-AIBP-yCD/TK that contained CD and TK double suicide genes driven by AFP promoter with AIBP gene overexpression was constructed, and then, the vectors were transfected into the Hep3B and SMMC7721 cells. After transfection, proliferation in both types of cells was determined by MTT assay, and the mRNA and protein expressions of AIBP, vascular endothelial growth factor (VEGF), VEGF receptor 2 (VEGFR-2) and matrix metallopeptidase 9 (MMP-9) were detected by RT-PCR and Western blot, respectively. Results: Both the AIBP mRNA and protein presented high expression in the normal hepatic cells, while those were significantly down-regulated in all the tested HCC cells with the down-regulation more evident in Hep3B and SMMC7721 cells. The recombinant plasmid pcDNA3.1-AFP-AIBP-yCD/TK was successfully constructed and transfected into Hep3B and SMMC7721 cells. After transfection, the proliferation of AFP-positive HepG2 cells was significantly inhibited, but the proliferation of AFP-negative SMMC7721 cells was not affected; in both types of cells, the mRNA and protein expressions of AIBP were remarkably increased, while the mRNA and protein expressions of VEGFR-2, VEGF and MMP-9 were reduced. Conclusion: AIBP expression is down-regulated in HCC cells, which is associated with the invasion and metastatic ability but not with the proliferative ability of HCC cells. Meanwhile, the combination gene vector pcDNA3.1-AFP-AIBP-yCD/TK has been successfully constructed.

Objective: To evaluate the efficacy of surgical intervention in the treatment of severe acute pancreatitis (SAP). Methods: The clinical data and results of 36 SAP patients undergoing surgical treatment from June 2009 to August 2012 were retrospectively analyzed. Results: Among the 36 SAP patients, 11 cases (30.5%) were caused by biliary factors, 2 cases (5.6%) were associated with pregnancy, 20 cases (55.6%) were due to alcohol abuse or overeating, and 3 cases were induced by other causes. Nine patients (25.0%) received early operation, of whom, 7 cases underwent cholecystectomy, choledocholithotomy, T-tube drainage, and peritoneal lavage, while 2 cases underwent exploratory laparotomy and irrigation/drainage of the pancreatic bed. Twenty-seven patients received delayed operation; all of them underwent pancreatic necrosectomy and peritoneal lavage, and in 4 cases cholecystectomy, choledocholithotomy and T-tube drainage were simultaneously performed. Two patients died of multiple organ dysfunction syndrome (MODS) and sepsis, 3 patients refused continued hospitalization and were lost to follow-up because of noncompliance, and all other patients were discharged after full recovery. Conclusion: Surgery is an important component in the treatment of SAP; appropriate timing and surgical treatment methods can reduce complications, improve therapeutic efficacy, and save the lives of critically ill patients.

Objective: To evaluate the efficacy and safety of laparoscopic and open splenectomy and esophagogastric devascularization for portal hypertension by means of systematic review. Methods: The literature of studies related to laparoscopic versus open splenectomy and esophagogastric devascularization was collected by searching the national and international online databases. The articles were screened according to the inclusion and exclusion criteria. After data extraction and quality assessment, Meta-analysis was performed by using RevMan 5.2 software. Results: No randomized controlled trial was found in the literature, and 11 non-randomized controlled clinical trials were finally included, with a total of 494 patients, of whom, 227 cases underwent laparoscopic surgery (laparoscopic group) and 267 cases were subjected to open surgery (laparotomy group). Compared with laparotomy group, the results of Meta–analysis showed that in laparotomy group, the operative time was prolonged, and the intraoperative blood loss, surgical complications and length of postoperative hospital stay was reduced, but the hospitalization costs were increased. All the differences reached statistical significance (all P<0.05). Conclusion: Compared with open surgery, laparoscopic splenectomy and esophagogastric devascularization has the advantages of reduced intraoperative blood loss, postoperative hospital stay and complications, but it has increased hospitalization costs and operative time. However, this conclusion should be considered cautiously, due to limitations in the quality and quantity of the included studies.