Abstract:

Objective: To assess the safety and efficacy of abdominal paracentesis drainage (APD) prior to percutaneous catheter drainage (PCD) in treatment of acute pancreatitis (AP), with the purpose of further optimizing the “step-up” approach for management of AP. Methods: The clinical data of 102 consecutive patients with moderately severe acute pancreatitis (MSAP) or severe acute pancreatitis (SAP) treated between June 2009 and June 2011 were retrospectively analyzed. All these patients underwent a “step-up approach”, beginning with conservative treatment, then PCD, and finally open necrosectomy if needed. Of the patients, 53 cases underwent APD prior to PCD (APD plus PCD group), and 49 cases received PCD alone (PCD alone group), and the relevant clinical parameters between the two groups of patients were compared. Results: The baseline data between the two groups were comparable. The fatality rate in APD plus PCD group was significantly lower than that in PCD alone group (3.8% vs. 8.2%, P<0.05); the incidence of infection had no statistical difference between the two groups (P>0.05), but the time to white blood cell recovery, incidence of sepsis as well as time for sepsis recovery, and hospitalization cost were reduced in APD plus PCD group versus PCD alone group (all P<0.05). In addition, comparison of the clinical data 2 d before PCD between the two groups showed that all the levels of inflammatory cytokines and all the scores yielded by different severity scoring systems in APD plus PCD group were lower than those in PCD alone group (all P<0.05). Conclusion: Using APD as a bridging treatment between conservative treatment and PCD for AP is safe and effective, without an increase of infections. APD can reduce the levels of inflammatory factors and incidence of sepsis through effectively evacuating the fluid collections, and thereby improve the prognosis of the patients.

Abstract:

Objective: To investigate the clinical efficacy of percutaneous catheter drainage (PCD) under the guidance of Color Doppler ultrasound in treatment of severe acute pancreatitis (SAP) with abdominal fluid collections. Methods: The clinical data of 131 SAP patients with confirmed fluid induced (type II) intra-abdominal hypertension during the course of SAP were collected. Of the patients, 65 cases underwent ultrasound-guided PCD (observational group), while the other 66 cases underwent conservative treatment (control group). The relevant clinical variables, efficacy indexes, and incidence of complications and mortality between the two groups were compared. Results: The pre-treatment data between the two groups were comparable. Observational group was superior to control group with regard to the time to disappearance of symptoms and signs, to blood amylase level recovery, and to diet resumption as well as the length of total hospital stay (all P<0.05). The urinary bladder pressure in both groups showed a decreased trend after treatment, but the decreasing speed in observational group was faster than that in control group (P<0.05). The incidence of complications was reduced and the effective rate of treatment was increased in observational group compared with control group (both P<0.05). There was no statistical difference in mortality between the two groups (P>0.05). Conclusion: Early PCD can reduce the abdominal pressure in SAP patients with abdominal fluid collections, decrease the incidence of complications and shorten the course of disease, but it has no significant effect on mortality.

Abstract:Objective: To determine the affecting factors for ultrasound-guided percutaneous catheter drainage (PCD) in treatment of severe acute pancreatitis (SAP) with infected necrosis and the efficacy of its combination with choledochoscopic necrosectomy. Methods: The clinical data of 65 SAP patients complicated with infected pancreatic necrosis undergoing ultrasound-guided PCD as initial treatment during January 2011 to December 2012 were retrospectively analyzed. Results: Thirty-eight patients (58.5%) were cured by PCD only, and in the 27 patients (41.5%) requiring further treatment after PCD, 4 cases were directly converted to open operation, and 23 cases (35.4%) underwent retroperitoneal choledochoscopic necrosectomy, of which 2 cases required an open conversion due to the procedure-related complications. Six patients (9.2%) died after PCD or PCD plus subsequent minimally invasive or open surgical treatment. Results from the comparison of the data between patients who were cured by PCD alone and those requiring further treatment showed that there were no statistically significant differences in the demographic data, severity scores, or other indexes such as white blood cell count, C-reactive protein level and prothrombin consumption test (all P>0.05), and no statistical difference as well in time of the first PCD or the diameter of the catheter drainage tube between them (all P>0.05), but the number of drainage tube placement was greater, drainage time was longer and incidence of complications was lower in the former than those in the latter, with statistical difference (all P<0.05). Conclusion: Number of drainage tube placement, drainage time and puncture-related complications are affecting factors for PCD, and PCD combined with choledochoscopic debridement is a safe and effective minimally invasive treatment for SAP with infected necrosis.

Abstract:Objective: To compare the values of BISAP, APACHE II, and Ranson’s scoring system for estimating the severity and prognosis of patients with early stage acute pancreatitis (AP). Methods: The clinical records of AP patients admitted between January 2009 and March 2014 were retrospectively analyzed. According to the first scores yielded by BISAP, APACHE II and Ranson’s score system at the time after admission, comparison was made of the area under the curve (AUC) of the receiver operating characteristic (ROC) curve of each scoring system for estimating the organ failure, pancreatic necrosis and death in AP patients as well as their sensitivity and specificity. Results: One hundred and thirty-five patients were finally enrolled according to the inclusion and exclusion criteria. Of the patients, 24 cases (17.7%) were diagnosed as severe acute pancreatitis (SAP), which included 19 cases diagnosed with organ failure, of which death occurred in 5 cases, and 20 cases were diagnosed having pancreatic necrosis. Of the BISAP, APACHE II, and Ranson’s scoring system, the AUC for organ failure estimation was 0.773, 0.821 and 0.897 (P<0.001), with sensitivity of 0.880, 0.872 and 0.740, and specificity of 0.530, 0.642 and 0.982, respectively; the AUC for pancreatic necrosis estimation was 0.819, 0.785 and 0.825 (P>0.05), with sensitivity of 0.715, 0.844 and 0.833, and specificity of 0.885, 0.630 and 0.672, respectively; the AUC for death estimation was 0.773, 0.786 and 0.889 (P>0.05), with sensitivity of 0.740, 0.843 and 0.865, and specificity of 0.830, 0.752 and 0.886, respectively. Conclusion: For AP patients, the three scoring systems have similar value in predicting pancreatic necrosis and death, and BISAP score is inferior to Ranson’s and APACHE II score in predicting organ failure, but it has the advantages of simple scoring, rapid assessment and dynamic monitoring, and is convenient to use in clinical practice.

Abstract:Objective: To compare the clinical efficacy of early enteral ecoimmunonutrition (EIN) and conventional early enteral nutrition (EN) in patients with severe acute pancreatitis (SAP). Methods: Sixty-four consecutive SAP patients were randomly designated to observational group and control group, with 32 cases in each group. Patients in both groups received early EN support, while those in observational group were additionally supplemented with glutamine granules and triple vital bacteria composition. The case dropout, and nutrition status, inflammatory indexes and positive rate of bacterial DNA extraction in whole blood and plasma levels of diamine oxidase (DAO), D-lactate acidosis, endotoxin as well as the lactulose to mannitol ratio (L/M) in urine before and 9 d after of EN support were observed in the two groups. Results: There were 4 dropout cases in control group who were not able to follow the requirements of the nutritional support. In both groups on 9 d after EN support compared with the data before EN support, the levels of serum albumin, prealbumin and transferrin were increased; the levels of interleukin-2, interleukin-6 and tumor necrosis factor-α were decreased; the positive rate of bacterial DNA extraction and the plasma levels of DAO, D-lactate acidosis, endotoxin and L/M ratio were decreased, however, the changing amplitudes in all these parameters in observational group were greater than those in control group (all P<0.05). Conclusion: Rational early EIN is beneficial in improving the nutrition status, inhibiting inflammatory responses and maintaining intestinal barrier function in SAP patients, so it is recommended to be used.

Abstract:Objective: To compare the efficacy of enteral nutrition (EN) supports at different timings in treatment of severe acute pancreatitis (SAP). Methods: Sixty-four SAP patients were selected and randomly designated to observational group and control group, with 32 cases in each group. On the base of the comprehensive therapy, patients in observational group received EN support within 24 h of admission, while those in control group underwent EN support later than 48 h after admission. The serum levels of C reactive protein (CRP), total protein (TP) and albumin (ALB), time for recovery of the blood and urinary amylase levels, APACHE II scores and length of hospital stay between the two groups were compared at 2 weeks after treatment. Results: The general data were comparable between the two groups before treatment. At 2 weeks after treatment, the CRP level was significantly decreased, while the TP and ALB levels were significantly increased in observational group compared with control group, and the time for recovery of the blood and urinary amylase levels and length of hospital stay were significantly shortened versus control group; the APACHE II scores in both groups were significantly decreased compared with their pretreatment values, but the decreasing degree in observational group was significantly greater than that in control group. All the above differences had statistical significance (all P<0.05). Conclusion: For SAP patients, early EN support is beneficial for maintaining intestinal mucosal barrier function and improving nutritional status, and thereby accelerating recovery.

Abstract:Objective: To evaluate the application value of the modified invagination pancreaticojejunostomy in pancreaticoduodenectomy (PD). Methods: The clinical data of 22 patients undergoing PD from February 2013 to October 2013 were retrospectively analyzed. Of the patients, 10 cases were subjected to traditional invagination pancreaticojejunostomy (traditional group) and 12 cases received the modified invagination pancreaticojejunostomy (modified group) during operation. The incidence of postoperative pancreatic fistula, operative time, intraoperative blood loss, and length of postoperative hospital stay between the two groups were compared. Results: The preoperative clinical data between the two groups were comparable. In modified group versus traditional group, the incidence of postoperative pancreatic fistula and operative time were significantly decreased (both P<0.05), while no statistical difference was noted in intraoperative blood loss and length of postoperative hospital stay (both P>0.05). Conclusion: Using modified invagination pancreaticojejunostomy in PD can reduce the incidence of postoperative pancreatic fistula and shorten the operative time, so it is recommended in clinical practice.

Abstract:Objective: To investigate the factors affecting the prognosis of patients with advanced pancreatic cancer after bypass palliation. Methods: The clinical data of 102 patients with advanced pancreatic cancer admitted from May 2005 to June 2013 who underwent palliative bypass surgery were reviewed. The postoperative survival status and prognostic factors were analyzed. Results: The median overall survival (OS) for the entire group of patients was 8.7 months, and the results of survival analysis showed that the median OS in patients with milder pain was higher than in those with severe pain, in ASA I/II patients was higher than in ASA III ones, in patients with normal C-creative protein (CRP) level was higher than in those with high CRP level, and in patients without metastasis was higher than in those with liver/peritoneal metastases, and all the differences had statistical significance (all P<0.05). Univariate analysis showed that the median OS of the patients was associated with the degree of pain, ASA classification, intraoperative blood loss, whether having liver/peritoneal metastases, and levels of CRP, CA19-9 and albumin (ALB) (all P<0.05). Further, multivariate COX regression analysis identified that ASA class III, severe pain, CRP≥5 mg/L and liver/peritoneal metastases were independent risk factors for prognosis of the patients. Conclusion: ASA class III, severe pain, high CRP level and liver/peritoneal metastases are indicators for a poor prognosis in advanced pancreatic cancer patients after palliative surgery.

Abstract:Objective: To investigate the expressions of miR-342-5p and its putative target gene Merlin in hepatocellular carcinoma (HCC) and the significance. Methods: The expressions of miR-342-5p and Merlin mRNA in HCC and tumor-adjacent tissues as well as in normal hepatic cell line and different HCC cell lines were determined by qRT-PCR method. HCCLM3 cells were transfected with lentiviral packaging plasmid pGCSIL-GFP-miR-342-5p or empty vector (negative control) with the untreated HCCLM3 cells as blank control, and then the invasion potential and migration activity were assessed by scratch-wound healing and Transwell migration assay, and the Merlin protein expression was measured by Western blot analysis, respectively. Using a dual-luciferase reporter assay system, the plasmids tagged with the 3’-UTR of the wild- or mutant-type Merlin gene (psiCHECK-Merlin) was co-transfected with pGCSIL-GFP-miR-342-5p or empty vectors (negative control), or transfected alone (blank control) into the HCCLM3 cells, and then the luciferase activity in each group of cells was detected. Results: Compared with tumor-adjacent tissue, the miR-342-5p expression was significantly up-regulated while Merlin mRNA expression was significantly down-regulated in HCC tissue (both P<0.05); in HCC tissues, the miR-342-5p expression was significantly higher while Merlin mRNA expression was significantly lower than that in non-vascular invasion group (P<0.05), in addition, the miR-342-5p and Merlin mRNA expression showed a negative correlation (r2=5.364, P<0.05). The miR-342-5p expression was significantly increased in all the studied HCC cell lines compared with the normal hepatic cell line, and was up-regulated with the increase of the invasion ability of the HCC cells, while the Merlin mRNA expression showed the exact opposite pattern (all P<0.05). In HCCLM3 cells transfected with pGCSIL-GFP-miR-342-5p, the invasion potential and migration activity were significantly reduced (both P<0.05) and the Merlin protein expression was elevated compared with those in blank control or negative control. In HCCLM3 cells co-transfected with psiCHECK-Merlin (wild-type) and pGCSIL-GFP-miR-342-5p, the luciferase activity was significantly decreased compared with its blank control or negative control (both P<0.05), but which showed no significant difference in HCCLM3 cells co-transfected with psiCHECK-Merlin (mutant-type) and pGCSIL-GFP-miR-342-5p compared with its blank control and negative control (P>0.05). Conclusion: Merlin is a target gene of miR-342-5p, and miR-342-5p may enhance the invasion and metastasis ability of HCC through regulating Merlin mRNA expression.

Abstract:Objective: To investigate the inhibitory effect of heat shock transcription factor 1 (HSF-1) on the inflammatory response induced by high-mobility group box-1 protein (HMGB1) and the mechanism. Methods: RAW264.7 cells were transfected with plasmid bearing HSF-1 gene (HSF-1 overexpression group) or empty plasmid (negative control group) respectively, using the untreated RAW264.7 cells as blank control group, and then the HSF-1 protein expression in each group of cells was determined by Western blot analysis. The above three groups of cells were stimulated with HMGB1 (1 μg/mL), and then in each groups of cells, the TNF-α levels were measured by ELISA assay, the proteins associated with mitogen-activated protein kinases (MAPK) and NF-κB pathways were detected by Western blot analysis, and NF-κB DNA binding activity was analyzed by electrophoretic mobility shift assay (EMSA), respectively. Results: Western blot analysis showed that the expression level of HSF-1 protein in HSF-1 overexpression group was significantly increased compared with negative control group or blank control group (both P<0.05), which had no significant difference between the two latter groups (P>0.05); after exposure to HMGB1 for 4 h, the TNF-α level in HSF-1 overexpression group was significantly decreased compared with negative control group or blank control group (both P<0.05), which had no significant difference between the two latter groups (P>0.05); after exposure to HMGB1 for different time periods, the expressions of MAPK pathway related proteins that included p-ERK, p-JNK and p-p38 as well as NF-κB pathway related protein p-IKα-B all showed no significant difference among the groups of cells (all P>0.05); results of EMSA showed that the expression of the gray-scale for NF-κB in HSF-1 overexpression group was significantly lower than that in negative control group or blank control group (both P<0.05), which had no significant difference between the two latter groups (P>0.05). Conclusion: HSF-1 overexpression can inhibit the TNF-α expression induced by HMGB1, and the mechanism may be associated with the NF-κB DNA binding activity but irrelevant to the MAPK signaling pathway.

Abstract:Objective: To investigate the role of Sonic Hedgehog (SHH) signaling pathway in proliferation of hepatocellular carcinoma (HCC) cells and the impacts of its inhibition on proliferation and chemosensitivity of HCC cells. Methods: Human HCC SMMC-7721 cells were respectively exposed to recombinant SHH N-terminus (rSHH-N), SHH neutralizing antibody (anti-SHH), and SHH pathway inhibitor cyclopamine for different time periods, and then the proliferation status of the cells was determined by MTT assay. The inhibitory effects on the proliferation of SMMC-7721 cells among 5-fluorouracil (5-FU), anti-SHH, cyclopamine, anti-SHH plus 5-FU and cyclopamine plus 5-FU were compared. Results: The proliferation of SMMC-7721 cells was significantly increased after rSHH-N treatment, while it was significantly decreased after anti-SHH or cyclopamine treatment, and all the effects presented a concentration- and time-dependent manner (all P<0.05). The inhibitory effect of anti-SHH plus 5-FU or cyclopamine plus 5-FU was significantly greater than any of the drugs used alone (all P<0.05). Conclusion: SHH signaling pathway plays an important role in growth of HCC cells, and blockage of SHH signaling pathway can inhibit proliferation of HCC cells and enhance their sensitivity to chemotherapeutic drugs.

Abstract:Objective: To investigate the miR-19 expression in hepatocellular carcinoma (HCC) tissue and its clinical significance. Methods: The miR-19 expression in 51 pairs of HCC tissues along with their matched adjacent tissues, and 10 samples of normal liver tissues were detected by qRT-PCR methods. The relations of miR-19 expression with the clinicopathologic factors and prognosis of HCC patients were analyzed. Results: The miR-19 expression level was increased in ascending order in normal liver tissue, tumor-adjacent tissue and HCC tissue, and the differences had statistical significance (all P<0.05). The miR-19 expression was significantly related to tumor size (P=0.02), metastasis (P=0.011), venous invasion (P=0.002) and AJCC stage (P=0.008) of the HCC patients, but irrelevant to their age, sex, tumor differentiation, satellite lesions, tumor number and AFP level (all P>0.05). The 5-year survival rate in patients with high miR-19 expression was significantly lower than that in those with low miR-19 expression (P<0.05). High miR-19 expression together with metastasis and venous invasion are risk factors affecting the survival of HCC patients (all P<0.05). Conclusion: The miR-19 expression is up-regulated in HCC tissue, which probably may be associated with the proliferation and metastasis of HCC, and high miR-19 expression may predict an unfavorable outcome.

Abstract:Objective: To determine the optimal digestive tract reconstruction method after total gastrectomy through comparison between the reconstruction with and without jejunal pouch and between the reconstruction with and without preservation of the duodenal passage. Methods: The relevant published literature of randomized controlled trials (RCTs) regarding the reconstruction methods following total gastrectomy was searched, and then systematic review and Meta-analysis for the included studies was performed. Results: Nine RCTs comparing Roux-en-Y reconstruction with and without pouch, and 4 RCTs comparing jejunal interposition with and without a pouch were included for Meta-analysis. In addition, 2 RCTs comparing Roux-en-Y reconstruction alone and with jejunal interposition, and 2 RCTs comparing jejunal interposition with and without a pouch were not applicable with Meta-analysis, but their results were presented as descriptive summary. Results of analysis showed that additional pouch formation versus no pouch did not significantly increase the incidence of perioperative mortality and complications, meanwhile, it significantly reduced the incidence of postoperative digestive tract problems such as dumping syndrome and burning sensation, and offered significantly improved food absorption and quality of life (all P<0.05). Compared with non-preservation of the duodenal passage, no evidence was noted for the benefits of the preservation of the duodenal passage in improvement of digestive tract reactions and quality of life regardless with or without a pouch (all P>0.05). Conclusion: The creation of a jejunal pouch is an effective digestive tract reconstruction procedure after total gastrectomy, while the preservation of the duodenal passage has no obvious advantage.

Abstract:Objective: To systematically evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) versus endoscopic mucosal resection (EMR) for early gastric cancer (EGC). Methods: The related literature of clinical studies was selected by searching several national and international databases, and the eligible studies that met the inclusion criteria were screened out and then assessed by Meta-analysis. Results: Fifteen case-control studies were finally included involving 4 673 patients, with 2 154 cases in ESD group and 2 519 cases in EMR group. Meta-analysis showed that the operative time was prolonged, but the en bloc resection rate, complete resection rate and curative resection rate were all increased in ESD group compared with EMR group (all P<0.05); as for the complications, the incidence of bleeding of the two groups had no statistical difference (P>0.05), but the incidence of gastric perforation was higher in ESD group than that in EMR group (P<0.05); the postoperative local recurrence rate in ESD group was lower than that in DMR group (P<0.05). Conclusion: For EGC, ESD offers high resection rate and low local recurrence rate, but has prolonged operative time and increased incidence of gastric perfusion. However, above conclusion needs further verification by high-quality clinical studies with larger sample size.

Abstract:

Objective: To assess the clinical efficacy of laparoscopic transabdominal preperitoneal approach (TAPP) for recurrent inguinal hernia after Lichtenstein hernioplasty. Methods: The clinical data of 12 patients with recurrent inguinal hernia after Lichtenstein surgery undergoing laparoscopic TAPP procedure between May 2009 and March 2014 in Xiangya Hospital were retrospectively analyzed. Results: Laparoscopic surgery was successfully performed in the entire group of patients, without any open conversion. The mean operative time was (110±25) min, and seroma occurred in 2 patients, which was resolved by needle aspiration. All patients recovered and were discharged from hospital within postoperative 48 h, and no re-recurrence was noted so far. Conclusion: Laparoscopic TAPP procedure is a safe and effective method in management of recurrent inguinal hernia after Lichtenstein repair.

Abstract:Objective: To evaluate the efficacy of modified Kugel patch repair for inguinal hernia in elderly patients. Methods: The clinical and follow-up data of 386 elderly patients over 60 years of age with inguinal hernia undergoing modified Kugel repair from February 2006 to June 2013 were retrospectively analyzed. Results: The operation was successfully performed in all patients. The operative time was 32-95 min, intraoperative blood loss was 50-150 mL in 6 cases and was less than 30 mL in all the remaining cases, time to first ambulation was 7-16 h, and length of postoperative hospital stay was 5-18 d. No surgical death and no cases of orchitis, seroma or scrotal hematoma occurred. Postoperative wound disruption, surgical site infection and lower-extremity deep venous thrombosis developed in one case (0.25%) each, 3 cases (0.78%) had moderate chronic pain and 46 cases (11.9%) had stretching pain in the operative area during walking for two weeks after operation. Follow-up of 3-65 months was obtained in 349 patients, and no postoperative recurrence was noted. Conclusion: Modified Kugel repair for inguinal hernia in elderly patients is safe and effective, and using high-quality patch with appropriate patch placement and fixation as well as sufficient and effective drainage of the surgical area, can promote the postoperative recovery of the patients.

Abstract:Acute pancreatitis (AP) is initiated by the activation of pancreatic enzymes triggered by a variety of causes, and characterized by inflammatory damage of the pancreas and commonly complicated with functional deterioration of other organs. Although AP in most patients is a mild and self-limited condition, 20% to 30% of cases will develop severe acute pancreatitis (SAP), which has a rapidly progressive course and no effective treatment, with an overall mortality of 5% to 10%. Nutrition support therapy is an important part of the integrated therapy program for AP, but there is no uniform protocol to be followed as yet. In this paper, the authors present the literature review of recent researches related to nutrition support therapy of AP.

Abstract:Pancreatic cancer is a highly lethal malignancy that responds poorly to current treatments and therefore has a dismal survival rate. Current progress in experimental molecular techniques has enabled detailed understanding of the molecular processes of pancreatic cancer development. Understanding of the molecular pathology should promote the development of new methodology for early diagnosis of pancreatic cancer, facilitate improvement in current approaches for pancreatic cancer treatment and improve its prognosis. Here, the authors present the current knowledge about the molecular alterations found in pancreatic cancer.

Abstract:Neuroendocrine tumors have a low prevalence and no specific symptoms, together with the lack of adequate research and understanding of them, leading to the unimproved survival of patients with this kind of disease over the past 30 years. In this paper, the authors overview the characteristics, diagnosis and management of pancreatic neuroendocrine tumors, based on the guideline of National Comprehensive Cancer Network (NCCN), and the consensus of European Neuroendocrine Tumor Society (ENETS) and North American Neuroendocrine Tumor Society (NANETS), in order to increase awareness of this condition.

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