Volume 25,Issue 9,2016 Table of Contents

1 Surgical managements of pancreatic cancer: current status and future directions

YANG Yinmo

2016, 25(9):1231-1235. DOI: 10.3978/j.issn.1005-6947.2016.09.001

[Abstract](243) [HTML](0) [PDF 1.23 M](1230)

Abstract:
The prognosis of patients with pancreatic carcinoma is the poorest of all the digestive system cancers, and the managements are very challenging. Now the treatment mode of pancreatic carcinoma is converting into “MDT” from “surgery first”. Neoadjuvant therapy is advocated for borderline resectable pancreatic carcinoma so as to increase rates of R0 resection. The standard lymphadenectomy is recommended in routine clinical practice except in special clinical trials. Pancreatic fistula is the severest complication of pancreatoduodenectomy. There are no significant differences in relation of methods of pancreatoenteric anastomosis to the occurrence of postoperative pancreatic fistula, so the quality of the anatomosis and the technical skills should be emphasized in order to decrease the incidence of pancreatic fistula.

2 Clinical significance of circulating tumor DNA detection for development of diagnosis and treatment of pancreatic cancer under the concept of precision medicine

QIN Renyi , ZHAO Yan

2016, 25(9):1236-1241. DOI: 10.3978/j.issn.1005-6947.2016.09.002

[Abstract](269) [HTML](0) [PDF 1.19 M](842)

Abstract:
Precision medicine is a novel medical concept and model, which developed from the base of personalized medicine, and with the rapid progress of genome sequencing technology and cross penetration of bioinformatics and big data science, and has increasingly shown its value in clinical treatment of malignant tumors. Over the recent years, the surgical techniques in pancreatic surgery has become more mature, along with the rapid development in a range of disciplines such as imaging technology, surgical instruments, energy platform, adjuvant therapies and targeted drugs, which provide a foundation and possibility for the treatment of pancreatic cancer, one of the most lethal solid malignant tumors, stepping into individualized stage. Circulating tumor DNA (ctDNA) bears the genetic characteristics of the tumors, and in this article, the authors address the clinical significance of ctDNA mutation detection in precision development direction of diagnosis and treatment of pancreatic cancer.

3 Radical pancreatic resection combined with vascular resection and reconstruction: a report of 12 cases

KUANG Tianzuo , YUAN Rongfa , HU Changchang , ZHANG Fuyang , ZHU Hongchao , HUANG Min

2016, 25(9):1242-1246. DOI: 10.3978/j.issn.1005-6947.2016.09.003

[Abstract](303) [HTML](0) [PDF 1.19 M](831)

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Objective: To investigate the feasibility, indications and intraoperative precautions of radical surgery with vascular resection and reconstruction for pancreatic cancer with vascular invasion. Methods: The clinical data of 12 patients with pancreatic cancer invading the portal vein (PV)/superior mesenteric vein (SMV) undergoing radical surgery from March 2014 to December 2015 were retrospectively analyzed. Ten patients underwent pancreaticoduodenectomy, and of them synchronously, 3 cases had PV resection, one case had SMV resection, and 6 cases had PV plus SMV resection with splenic vein ligation without reconstruction, of whom, 5 cases had spleen preservation and one case had splenectomy due to severe splenic congestion; two patients underwent resection of the body and tail of the pancreas, and both cases had synchronous PV plus SMV resection and splenectomy. Portal vein occlusion time ranged from 16 to 30 min; end to end vascular anastomosis was performed in 10 cases and vascular prosthesis was used in 2 cases. Results: All 12 patients recovered uneventfully, and no perioperative death or complications such as biliary fistula, pancreatic fistula, bleeding, thrombosis, prosthetic graft infection and liver function failure occurred, and no manifestations of regional portal hypertension were found in the short-term after operation. Conclusion: Pancreaticoduodenectomy or resection of the body and tail of the pancreas in combination with vascular resection is feasible for selected cases in qualified hospital, and can increase the resectability rate, improve patients’ quality of life, with no increase in operative mortality and incidence of complications. However, it requires careful intraoperative anatomic dissection and meticulous operation as well as achievement of radical resection visible to the naked eye, for improving the safety of the operation and long-term survival rates.

4 Prognostic factors for adenocarcinoma of the ampulla of Vater after pancreaticoduodenectomy

HUANG Xiuyun , WANG Xiangyang , YANG Yuming , WU Minghao , LIU Zhan

2016, 25(9):1247-1252. DOI: 10.3978/j.issn.1005-6947.2016.09.004

[Abstract](436) [HTML](0) [PDF 1.09 M](1138)

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Objective: To investigate the prognostic factors in patients with adenocarcinoma of the ampulla of Vater after pancreaticoduodenectomy. Methods: The clinical and pathological data of patients with adenocarcinoma of the ampulla of Vater undergoing pancreaticoduodenectomy from January 2007 to December 2014 were reviewed. The influential factors for postoperative survival of the patients were analyzed. Results: In the entire group of patients, the postoperative 1-, 3- and 5-year survival rate was 87.5%, 64.3% and 54.5% respectively. Univariate analysis showed that preoperative level of total bilirubin, direct bilirubin, CEA, CA19-9 and CA242 and degree of tumor differentiation, depth of infiltration, lymphatic metastasis, tumor stage, involvement of pancreas, neural invasion and postoperative adjuvant therapy were influential factors for survival. Multivariate analysis indicated that preoperative CEA level and depth of infiltration were independent prognostic factors (both P<0.05). Conclusion: Multiple factors are related to the prognosis of patients with adenocarcinoma of the ampulla of Vater after pancreaticoduodenectomy, and among them, the CEA level and the depth of infiltration are the most important indicators for estimating the prognosis of the patients.

5 Efficacy analysis of local resection of the body and tail of the pancreas combined with vascular resection and reconstruction for advanced pancreatic cancer

HUANG Jiang , BAI Lijie , ZHANG Shengjun , ZHANG Xiaorong

2016, 25(9):1253-1258. DOI: 10.3978/j.issn.1005-6947.2016.09.005

[Abstract](244) [HTML](0) [PDF 1.34 M](753)

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Objective: To analyze the efficacy of local resection of the body and tail of the pancreas combined with vascular resection and reconstruction in treatment of advanced pancreatic cancer. Methods: Fifty-eight patients with advanced pancreatic cancer in the body and tail of the pancreas admitted from 2010 to 2012 were divided into observational group and control group. Patients in observational group underwent local resection of the body and tail of the pancreas combined with vascular resection and reconstruction plus postoperative chemotherapy, and those in control group received chemotherapy only. The treatment effects and survivals between the two groups of patients were compared, and the prognostic factors for the patients were also analyzed. Results: The general data of the two groups of patients were comparable. In observational group compared with control group, the objective response rate (44.9% vs. 6.9%) and disease control rate (82.8% vs. 55.2%) were significantly increased (both P<0.05); the half-year survival rate (79.3% vs. 48.3%), 1-year survival rate (55.2% vs. 17.2%), mean survival time (17.6 months vs. 10.3 months), overall survival rate and progression-free survival rate were all significantly improved (all P<0.05). There was no significant difference in incidence of adverse reactions between the two groups (P>0.05). Univariate analysis showed that tumor stage and presence or absence of lymph node/vessel metastasis were influential factors for progression-free survival of the patients (both P<0.05). Conclusion: For patients with advanced pancreatic cancer who are able to receive surgical treatment, local resection of the body and tail of the pancreas combined with vascular resection and reconstruction may offer better results, and it is recommended to be used.

6 Safety and efficacy of nanoknife ablation for locally advanced unresectable pancreatic cancer

LIU Shaopeng , LI Xiaoyong , CHENG Bingbing

2016, 25(9):1256-1265. DOI: 10.3978/j.issn.1005-6947.2016.09.006

[Abstract](478) [HTML](0) [PDF 1.54 M](824)

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Objective: To evaluate the clinical value of nanoknife ablation in treatment of locally advanced unresecable pancreatic cancer. Methods: From September 2015 to March 2016, 18 patients with locally advanced unresectable pancreatic carcinoma received nanoknife ablation treatment. The clinical variables of the patients before and after treatment were comparatively analyzed. Results: All patients underwent successful operation, and all vital signs were stable throughout the procedures. The serum amylase concentration of the patients was significantly increased on postoperative day 1 (P<0.05), but then, it gradually decreased to the normal level; the CA19-9 level of the patients presented a slowly decreasing trend after operation, which was significantly lower than that of preoperative value at each studied postoperative time point (all P<0.05); the myocardial enzyme indexes showed no significant difference before and after operation (all P>0.05). Within postoperative 3 months, pancreatitis occurred in 2 cases (11%), and hypoglycemia, hyperglycemia and gastric emptying dysfunction occurred in one case each (5%), which were all quickly relieved after symptomatic treatment, while no treatment-related complications such as pancreatic leakage, hemorrhage, and bile leakage occurred. The scores for quality of life and Karnofsky of the patients were significantly increased after operation compared with preoperative values (all P<0.05). According to the EORTC criteria, complete metabolic remission was achieved in 2 cases (11%), partial metabolic response was obtained in 10 cases (55%), stable metabolic disease was seen in 3 cases (17%), and progressive metabolic disease was found in 3 cases (17%), and the objective response rate was 67% and disease control rate was 83%, respectively. Conclusion: Nanoknife ablation has high safety and demonstrable efficacy in treatment of locally advanced unresecable pancreatic cancer, and it may have a great application potential.

7 SHH protein expression in pancreatic cancer tissue and its clinical significance

LIN Songting , CHEN Zhengyi , ZHONG Wenzhou

2016, 25(9):1266-1270. DOI: 10.3978/j.issn.1005-6947.2016.09.007

[Abstract](390) [HTML](0) [PDF 575.84 K](688)

Abstract:
Objective: To investigate the expression of embryonic developmental signal pathway protein SHH in pancreatic cancer tissue and its clinical significance. Methods: The SHH expression in 45 specimens of pancreatic cancer tissue and 30 specimens of pancreatic tissue with benign disease were detected by immunohistochemical staining, and the relations of SHH expression with the clinicopathologic factors and prognosis of the pancreatic cancer patients were analyzed. Results: The positive SHH expression rate in pancreatic cancer tissue was significantly higher than that in pancreatic tissue with benign disease (66.67% vs. 0.00%, P<0.05). The positive SHH expression was significantly associated with lymph node metastasis, degree of tumor differentiation and TNM stage of the patients (all P<0.05). There was no significant difference in 3-year survival rate and median survival time between pancreatic cancer patients with positive and negative SHH expression (26.67% vs. 20.00%; 18.4 months vs. 15.6 months, both P>0.05). Conclusion: The positive SHH expression rate is increased in pancreatic cancer tissue, and its positive expression may be associated with the disease progression of the patients, but whether it has a relationship with long-term prognosis is uncertain.

8 Expression of insulin-like growth factor mRNA binding protein 3 in pancreatic cancer and its significance

JIANG Meiping , JU Yunhe

2016, 25(9):1271-1275. DOI: 10.3978/j.issn.1005-6947.2016.09.008

[Abstract](260) [HTML](0) [PDF 1.30 M](796)

Abstract:
Objective: To investigate the expression of insulin-like growth factor mRNA binding protein 3 (IMP3) in pancreatic cancer tissue and its clinical significance. Methods: The IMP3 expressions in 126 specimens of pancreatic cancer tissue and 12 specimens of normal pancreatic tissue were determined by immunohistochemical staining. The relations of IMP3 expression with clinicopathologic factors and prognosis of pancreatic cancer patients were analyzed. Results: The IMP3 positive expression rate in pancreatic cancer tissue was significantly higher than that in normal pancreatic tissue (93.65% vs. 0.00%, P<0.000). The IMP3 expression was significantly associated with the tumor size, lymph-node metastasis, depth of invasion and TNM stage of the pancreatic cancer patients (all P<0.05); the median survival time in patients with high IMP3 expression was significantly shorter than that in patients with low IMP3 expression (9.5 months vs. 17.8 months, P=0.000). Conclusion: IMP3 expression rate is increased in pancreatic cancer tissue, and its expression level may be closely related to the occurrence and development of pancreatic cancer. Further, those patients with high IMP3 expression may face a poor prognosis.

9 TAp63 expression in pancreatic cancer and its significance

YU Yaqun , MO Qingrong , LI Shuqun , CHEN Qian , LIAO Weijia

2016, 25(9):1276-1281. DOI: 10.3978/j.issn.1005-6947.2016.09.009

[Abstract](394) [HTML](0) [PDF 1.18 M](789)

Abstract:
Objective: To investigate TAp63 expression in pancreatic cancer and its significance. Methods: The mRNA and protein expressions of TAp63 in 21 paired specimens of pancreatic cancer tissues and their adjacent normal pancreatic tissues, as well as three different pancreatic cancer cell lines (PANC-1, CFPAC-1 and BxPC3) and normal pancreatic cell line (HPDE6-C7) were determined by real-time PCR and Western blot, respectively. PANC-1 cells were transfected with TAp63-siRNA, and then, the changes in mRNA and protein expressions of TAp63 were observed and the proliferation of PANC-1 cells after transfection was detected by MTT and BrdU assay, respectively. Results: The TAp63 mRNA expression level in pancreatic cancer tissue was significantly lower than that in their adjacent normal pancreatic tissues (t=2.572, P=0.0158); both mRNA and protein expression levels of TAp63 were significantly lower in all the three types of pancreatic cancer cell lines than those in HPDE6-C7 cells (all P<0.05). In PANC-1 cells transfected with TAp63-siRNA compared with untreated PANC-1 cells, both the abilities of proliferation and DNA synthesis were significantly increased (all P<0.05). Conclusion: TAp63 expression is down-regulated in pancreatic cancer tissue and cells, and the lower the level of TAp63 expression, the stronger is the growth ability of the cells.

10 Influence of COX-2 specific inhibitor NS-398 on growth and tumor angiogenesis of pancreatic cancer

ZHANG Xu , GE Chunlin

2016, 25(9):1282-1290. DOI: 10.3978/j.issn.1005-6947.2016.09.010

[Abstract](218) [HTML](0) [PDF 2.65 M](806)

Abstract:
Objective: To investigate the influence of COX-2 specific inhibitor NS-398 on growth of pancreatic cancer and its mechanism. Methods: The expressions of COX-2 and VEGF in different human pancreatic cancer cell lines (BxPC-3, SWl990, Capan-2, Aspc-1, PANC-1) were determined by qRT-PCR and Western blot respectively, and the inhibitory effects of NS-398 on proliferation of each pancreatic cancer cell line in vitro were measured by MTT assay. Orthotopic transplantation models of pancreatic cancer using the most sensitive cell line identified by in vitro tests were established in nude mice, and then the tumor-bearing mice were randomly divided into experimental group and control group, which underwent treatment with NS-398 or normal saline respectively. The growths of the tumor xenografts in the two groups were compared and the expressions of COX-2 and VEGF protein as well as microvessel density (MVD) in the tumor tissues were detected. Results: All the pancreatic cancer cell lines presented COX-2 and VEGF expressions with varying degrees; NS-398 inhibited the in vitro proliferation of all the pancreatic cancer cells in time- and concentration-dependent manner, and among them, Bxpc-3 cells had the highest expression levels of COX-2 and VEGF, and were also most sensitive to NS-398. After establishment of orthotopic pancreatic cancer model with Bxpc-3 cells, in mice in experimental group compared with those in control group, the average tumor volume was significantly reduced (20.215 2 mm3 vs. 204.444 4 mm3), and the expression levels of COX-2 and VEGF as well as MVD were all significantly reduced (all P<0.05). Conclusion: NS-398 has inhibitory effect on growth of pancreatic cancer, and the mechanism may be related to its decreasing VEGF gene expression via COX-2 pathway and thereby reducing tumor angiogenesis.

11 Role of HSF-1 in inflammatory response induced by HMGB1

YIN Chaoqi , HE Quanyong , LUO Chengqun , ZHOU Jianda , CHEN Jia , LI Ping , ZHU Jie ,

2016, 25(9):1291-1295. DOI: 10.3978/j.issn.1005-6947.2016.09.011

[Abstract](216) [HTML](0) [PDF 1.22 M](686)

Abstract:
Objective: To investigate the role of heat shock transcription factor 1 (HSF1) in inflammatory response induced by high mobility group protein B1 (HMGB1). Methods: The TNF-α contents in the supernatants of RAW264.7 cells after exposure to different concentrations of HMGB1 for different times were determined by ELISA assay. The NF-κB nuclear translocation and HSF-1 expression in RAW264.7 cells after HMGB1 treatment were examined by immunofluorescence and Western blot, respectively. The change in TNF-α expression induced by HMGB1 in RAW264.7 cells after interference of HSF-1 expression was observed. Results: RAW264.7 cells presented two peaks of TNF-α release at 4 and 12 h respectively after HMGB1 treatment, and the TNF-α release level was increased with the elevation of HMGB1 concentration. The NF-κB nuclear translocation was significantly enhanced and HSF-1 expression was significantly increased in RAW264.7 cells after HMGB1 treatment (both P<0.05). The TNF-α expression induced by HMGB1 in RAW264.7 cells after interference of HSF-1 expression was significantly increased compared with RAW264.7 cells without HSF-1 interference (P<0.05). Conclusion: HMGB1 can induce inflammatory response and HSF-1 expression in RAW264.7 cells, but HSF-1 may play a negative feedback inhibitory role in the HMGB1-induced inflammation.

12 Changes in XIAP and SMAC levels in tumor tissue and serum of patients with cholangiocarcinoma and their clinical significance

CHEN Lei , SHANG Peizhong

2016, 25(9):1296-1301. DOI: 10.3978/j.issn.1005-6947.2016.09.012

[Abstract](210) [HTML](0) [PDF 1.50 M](775)

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Objective: To investigate the expressions of XIAP and SMAC in cholangiocarcinoma tissues and their serum levels in cholangiocarcinoma patients and then to analyze their clinical significance. Methods: The expressions of XIAP and SMAC in cholangiocarcinoma tissues together with the tumor adjacent tissues from 54 cholangiocarcinoma patients were detected by immuneohistochemical staining, and the serum levels of XIAP and SMAC in 25 cholangiocarcinoma patients and 15 healthy subjects were determined by ELISA assay. The relations of their expressions with clincopathologic factors of the patients and the changes in their serum levels in the patients before and after operation were analyzed. Results: In cholangiocarcinoma tissues compared with their adjacent tissues, the positive expression rate of XIAP was significantly increased (81.45% vs. 30.00%, P<0.05), while the positive expression rate of SMAC was significantly decreased (38.89% vs. 80.00%, P<0.05). The XIAP expression was significantly related to the pathological classification and presence or absence of lymph node metastasis, while SMAC expression was significantly related to the TNM stage and presence or absence of lymph node metastasis (all P<0.05), and there was a negative correlation between XIAP and SMAC expression in cholangiocarcinoma tissue (r=-0.327, P<0.05). In cholangiocarcinoma patients, the preoperative serum XIAP level was significantly higher and SMAC level was significantly lower than those in healthy control subjects (both P<0.05), and both of them tended to be normal after operation. The expressions of XIAP and SMAC in cholangiocarcinoma tissue and their serum levels in these patients had significant consistency (r=0.381, P=0.025; r=0.623, P=0.000). Conclusion: XIAP expression is increased and SMAC expression is decreased in cholangiocarcinoma, and their combined detection may have certain significance for early diagnosis and estimation of therapeutic effect and prognosis of cholangiocarcinoma.

13 Staged sequential minimally invasive approach for acute biliary pancreatitis: a report of 112 cases

LI Jun , XIE Jiang , LIAO Zuofu , YU Yang , CHEN Zhonghao

2016, 25(9):1302-1306. DOI: 10.3978/j.issn.1005-6947.2016.09.013

[Abstract](218) [HTML](0) [PDF 1.11 M](900)

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Objective: To investigate the efficacy of staged sequential minimally invasive approach for acute biliary pancreatitis (ABP). Methods: From January 2013 to December 2015, 112 patients with ABP received basic conservative treatment together with staged sequential minimally invasive management, which included endoscopic nasobiliary drainage (ENBD) followed by endoscopic sphincterotomy (EST) plus basket stone extraction, and then, elective laparoscopic cholecystectomy (LC) or LC plus laparoscopic common bile duct exploration (LCBDE), and individualized treatment based on minimally invasive therapy. Results: In all 88 patients with mild or moderate disease, the etiologic biliary stones were extracted during hospitalization, and they were cured and discharged from hospital with no mortality and an average length of hospital stay of (7.5±2.3) d; in the 24 patients with severe disease, 2 cases died of multi-organ failure, and the remaining cases were cured and discharged from hospital uneventfully, with an average length of hospital stay of (21.2±5.3) d. Conclusion: Staged sequential minimally invasive method has definite efficacy in treatment of ABP, with advantages of thorough resolution of the cause of disease during one-admission and reduced length of hospitalization.

14 Value of drain fluid amylase level obtained on the first postoperative day in prediction of pancreatic fistula

CHENG Dongdong , LIU Ning , WU Zhaodong

2016, 25(9):1307-1312. DOI: 10.3978/j.issn.1005-6947.2016.09.014

[Abstract](201) [HTML](0) [PDF 1.14 M](860)

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Objective: To investigate the value of drain fluid amylase level obtained on the first postoperative day (DFA1) in predicting pancreatic fistula (PF). Methods: The clinical data of all patients undergoing pancreatic resection from February 2011 to February 2016 in the Affiliated Hospital of Taishan Medical College and FeichengKuangye Central Hospital were reviewed, and those with DFA1 data were selected. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of DFA1 for predicting PF were analyzed by receiver operating characteristic (ROC) curve, and the risk factors for PF were also determined. Results: A total of 125 patients underwent pancreatic resection and 67 cases (55 cases undergoing pancreaticoduodenectomy and 12 cases undergoing distal pancreatectomy) of them had DFA1 data. Of the 67 patients, PF occurred in 15 cases, which was classified as grade A in 7 cases (10.45%), grade B in 6 cases (8.96%) as and grade C in 2 cases (2.99%). ROC curve analysis showed that DFA1 had significant predictability on PF (P<0.05), and the sensitivity, specificity, PPV and NPV were 100%, 80.8%, 60.0% and 100.0% respectively at the cutoff value of 340 U/L. Univariate analysis indicated that DFA1, pancreatic duct diameter ≤ 3 mm and soft pancreatic texture were risk factors for PF (all P<0.05), and the Logistic regression analysis identified that DFA1 was an independent risk factor for PF (P<0.05). Conclusion: DFA1 is an independent risk factor for PF and has better value in predicting PF. Aggressive preventive measures should be made against PF in patients with DFA1>340 U/L.

15 Comparison of different treatment methods for severe acute pancreatitis with massive peripancreatic fluid collections

HONG Lei , XIANG Heping

2016, 25(9):1313-1318. DOI: 10.3978/j.issn.1005-6947.2016.09.015

[Abstract](479) [HTML](0) [PDF 1.13 M](682)

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Objective: To investigate different treatment methods of SAP with massive peripancreatic fluid collections. Methods: The clinical data of 162 patients with SAP and concomitant massive peripancreatic fluid collections treated during October 2008 to May 2015 were retrospectively analyzed. Of the patients, 68 cases underwent conservative treatment (conservative treatment group), 67 cases underwent ultrasound or CT guided percutaneous puncture and catheter drainage (puncture drainage group), 13 cases underwent laparoscopic surgery (laparoscopic group) and 14 cases underwent traditional open surgery (laparotomy group). The relevant clinical variables among groups were compared. Results: The general data of the four groups were comparable. The times for disappearance of symptoms and for recovery of serum amylase in puncture drainage group and laparoscopic group were significantly shorter than those in conservative treatment group, and the times for most abdominal effusion absorption and bladder pressure decrease in conservative treatment group were significantly later than those in the other three groups (all P<0.05). In puncture drainage group or laparoscopic group, the length of hospital stay was significantly shorter and incidence of complications was significantly lower than those in conservative treatment group or laparotomy group (all P<0.05). The effective success rate was significantly lower and re-operation rate was significantly higher in conservative treatment group than those in the other three groups (all P<0.05). The mortality rates were significantly increased in conservative treatment group and laparotomy group compared with puncture drainage group or laparoscopic group (all P<0.05). Conclusion: Ultrasound or CT guided percutaneous puncture and catheter drainage or catheter drainage via laparoscopic retroperitoneal approach has demonstrable efficacy in treatment of SAP with massive peripancreatic fluid collections, with advantages of low incidence of complications and mortality rates.

16 Surgical treatment strategies for wall-off pancreatic necrosis with multi-drug resistant organism infections

SHEN Dingcheng , ZHOU Shuyi , HUANG Gengwen , KANG Hao

2016, 25(9):1319-1323. DOI: 10.3978/j.issn.1005-6947.2016.09.016

[Abstract](373) [HTML](0) [PDF 1.79 M](745)

Abstract:
Objective: To investigate the surgical treatment strategies for wall-off pancreatic necrosis (WOPN) with multi-drug resistance organisms (MDRO) infections. Methods: The clinical data of 57 WOPN patients with clear pathogenic evidence treated between October 2010 and June 2016 were retrospectively analyzed, and the treatment and outcomes of 35 cases with MDRO infections among them were independently summarized. Results: The mortality in the entire group of patients was 29.8% (17/57), which in patients with MDRO infections was 40.0% (14/35) and in those with common bacterial infections was 13.6% (3/22), and the difference had statistical significance (P<0.05). In patients with MDRO infections compared with patients with common bacterial infections, the severity of acute pancreatitis was aggravated, number of surgical interventions was increased, length of ICU stay was prolonged and hospitalization cost was increased (all P<0.05). Fifty patients (87.7%) received step-up surgical treatment with initial percutaneous catheter drainage (PCD) , followed by minimal access retroperitoneal pancreatic necrosectomy (MARPN) or open pancreatic necrosectomy (OPN) if necessary, and the overall cure rate was 72.0% and the cure rate in cases with MDRO infections was 60.6%; 7 patients (12.3%) underwent step-down surgical treatment with initial OPN directly, or combined with PCD and MARPN later, and the overall cure rate was 71.4% and the cure rate in cases with MDRO infections was 50.0%. A total of 50 MDRO pathogens were detected in the whole group of patients and the top five commonest pathogens were MDR-Acinetobacterbaumanni (36.0%, 18/50), MDR-Klebsiella pneumonia (20.0%,10/50), Escherichia coli with extended-spectrum β-lactamases (14.0%, 7/50), MDR-Pseudomonas aeruginosa (10.0%, 5/50) and MDR-Enterobacter cloacae (8.0%, 4/50), respectively. Conclusion: Step-up strategy is the first choice for WOPN, and those with MDRO infections may have unfavorable outcomes, for whom, more aggressive surgical treatment strategies are always required.

17 Surgical treatment of biliary duct diseases in acute biliary pancreatitis

朱永吉|谢坤|赵义军|孙昀|黄帆|耿小平

2016, 25(9):1324-1330. DOI: 10.3978/j.issn.1005-6947.2016.09.017

[Abstract](237) [HTML](0) [PDF 1.19 M](839)

Abstract:
Objective: To investigate the method and timing of surgical treatment of biliary duct diseases in patients with acute biliary pancreatitis (ABP). Methods: The clinical data of 206 ABP patients undergoing surgical treatment for bile duct diseases were retrospectively analyzed. Of the patients, 192 cases had mild disease, 2 cases had moderately severe disease, and 12 cases had severe disease. The surgical procedures included cholecystectomy, choledocholithotomy-T-tube drainage, ERCP and partial hepalobectomy. Results: All patients with moderately severe or severe ABP underwent early surgical treatment after non-surgical treatment. In patients with mild ABP, the time of antibiotic administration, overall length of hospital stay and hospitalization cost were significantly reduced in cases undergoing early surgical treatment (within two weeks of onset) compared with those undergoing delayed surgical treatment (after two weeks of onset), and the time of antibiotic administration, overall length of hospital stay and total cost in cases undergoing surgical treatment during admission were significantly reduced compared with those undergoing elective surgery (all P<0.05). Conclusion: Biliary tract surgery in ABP patients should be tailored according to patient’s specific condition, which should be performed during the time of same admission and early after onset for mild cases, and in severe cases, it should be performed as soon as possible after the relief of the overall conditions by non-surgical treatment. Emergency surgery or ERCP should be performed for those with biliary obstruction or cholangitis regardless of mild or severe presentation.

18 Alterations in peripheral blood levels of NGAL and ghrelin in patients with acute pancreatitis and their significance

AN Dong , XU Lei

2016, 25(9):1331-1335. DOI: 10.3978/j.issn.1005-6947.2016.09.018

[Abstract](395) [HTML](0) [PDF 1.10 M](762)

Abstract:
Objective: To investigate the relations of levels of neutrophil gelatinase associated lipid lipocalin (NGAL) and ghrelin in peripheral blood of patients with the severity of illness of patients with acute pancreatitis (AP). Methods: The clinical data of 199 AP patients treated previously were collected. Of the patients, 103 cases had mild AP (MAP) and 96 cases had severe AP (SAP); 17 cases (8.54%) died during admission. The differences in NGAL and ghrelin levels and other parameters on the first day of admission were compared between patients with different severity of disease and different outcomes, respectively. Results: In patients with SAP, the levels of NGAL, ghrelin, C-reactive protein (CRP), white blood cells (WBC), serum amylase, procalcitonin (PCT), and APACHE II score, Balthazar CT score and BISAP index were significantly increased compared with patients with MAP (all P<0.05); in patients who died during treatment, all the above-mentioned parameters were also significantly higher than those in patients who were cured (all P<0.05). In the 199 patients, the peripheral blood levels of both NGAL and ghrelin had significant correlation with BISAP index (r=0.579 and 0.482, both P<0.05), and their correlation were superior to those of serum amylase, WBC and PCT with BISAP index. Conclusion: The peripheral blood levels of NGAL and ghrelin in AP patients are closely related to the severity of illness of the patients, and their increase may indicate increased risk of poor prognosis of patients.

19 Comparison of three different methods for hepatic inflow occlusion in laparoscopic left lateral hepatic lobectomy

XIA Zhichao , ZENG Zhong , XIA Renpin , YANG Shikun , HUANG Hanfei , XU Wanggang , LIN

2016, 25(9):1336-1340. DOI: 10.3978/j.issn.1005-6947.2016.09.019

[Abstract](207) [HTML](0) [PDF 1.09 M](792)

Abstract:
Objective: To compare the clinical effects of three different methods for hepatic inflow occlusion in laparoscopic left lateral hepatic lobectomy. Methods: The clinical data of 45 patients undergoing laparoscopic left lateral hepatic lobectomy for primary hepatocellular carcinoma during 2008 to 2015 were retrospectively analyzed. The intraoperative hepatic inflow control of the patients was performed by Pringle's maneuver (total hepatic occlusion group, 18 cases), hemihepatic vascular occlusion (hemihepatic occlusion group, 17 cases), and stepped occlusion of seven-step liver transection method (seven-step liver transection group, 10 cases). The major clinical variables among the three groups of patients were compared. Results: The intraoperative blood loss showed no statistical difference among the three groups (P>0.05), but the operative duration, postoperative liver function recovery, gastrointestinal functional recovery, incidence of postoperative complications and length of hospital stay in seven-step liver transection group were all significantly superior to those in total hepatic occlusion group and hemihepatic occlusion group (all P<0.05). Conclusion: Using seven-step method in laparoscopic left lateral hepatic lobectomy is safe, simple and feasible, with no special laparoscopic skill requirements for performers, so it is recommended to be used in hospitals of different levels.

20 Central hepatocellular carcinoma resection via separation of middle hepatic fissure: a report of one case and review of literature

YUAN Rongfa , LEI Jun , WU Linquan , SHAO Jianghua

2016, 25(9):1341-1345. DOI: 10.3978/j.issn.1005-6947.2016.09.020

[Abstract](374) [HTML](0) [PDF 1.90 M](825)

Abstract:
Objective: To investigate the preoperative evaluation and surgical methods for central hepatocellular carcinoma. Methods: The clinical data of a patient with primary hepatocellular carcinoma located in deep position of segment VIII was analyzed retrospectively, and relevant literature review was also made. Results: Before operation, accurate liver function assessment and precise tumor localization, and then careful surgical planning were made for this patient; during operation, the liver parenchyma was split along the median fissure of the liver from the second porta hepatis at its superior plane to the first porta hepatis at its inferior plane, and then, liver parenchyma was separated along the line of the right hepatic vein, and was converged with the divided median fissure of the liver, after which, the tumor was completely excised with complete preservation of the right and middle hepatic veins. Postoperative CT examination showed that the right and middle hepatic veins were patent. Conclusion: Surgery for central hepatocellular carcinoma is difficult and has high risk. Adequate preoperative evaluation and appropriate selection of surgical methods are critical for surgical success.

21 Endovascular therapy of deep venous thrombosis induced by Cockett's syndrome: a report of 27 cases

LI Zhenzhen , XIAO Zhanxiang , LI Zhuori , ZENG Zhaofan , WU Hongfei , Zhang Wenbo

2016, 25(9):1346-1356. DOI: 10.3978/j.issn.1005-6947.2016.09.021

[Abstract](220) [HTML](0) [PDF 2.13 M](749)

Abstract:
Objective: To investigate the endovascular treatment methods for deep venous thrombosis (DVT) of the lower extremities induced by Cockett’s syndrome (CS). Methods: The clinical data of 27 patients with DVT caused by CS treated from July 2012 to April 2016 were retrospectively analyzed. Of the patients, all cases received leg venography; 18 cases underwent placement of a temporary inferior vena cava filter, followed by iliac vein balloon dilatation and catheter-directed thrombolysis (CDT) for deep vein thrombosis, and 6 of them had stent placement; 7 cases underwent venography of the deep leg veins and simple deep vein CDT; 2 cases underwent only superficial venous thrombolysis. Results: Twenty-three patients recovered well after operation, and their deep veins were found patent by review venography, and the other 4 patients had mild to moderate leg swelling at discharge. The filters in 2 patients became permanent because of thrombus trapped inside the filter. No pulmonary embolism or critical bleeding occurred during the perioperative period. All patients were followed up for one month to 3 years (average of 18 months), of whom, 3 cases presented lower limb swelling after movement, but this did not occur in the other 24 cases, and remission rate was 88.9%; on duplex ultrasonic examination, the iliac vein was found to be occluded in 4 cases and patent in the remaining 23 cases, and the patency rate was 85.2%. Conclusion: Endovascular therapy as a safe and minimally invasive procedure can effectively deal with CS with concomitant DVT.

22 Research progress in molecular targeted therapy for pancreatic cancer

ZHONG Zhiwei , YIN Xiangbao

2016, 25(9):1351-1356. DOI: 10.3978/j.issn.1005-6947.2016.09.022

[Abstract](222) [HTML](0) [PDF 1.11 M](986)

Abstract:
Pancreatic cancer is one of most malignant tumors with extremely poor prognosis, and the 5-year survival rate of the patients is below 5%. Conventional treatments produce very limited effects for pancreatic cancer, and it requires multidisciplinary approach and comprehensive management. With the deepening knowledge of molecular biology, molecular targeted drugs such as epidermal growth factor receptor inhibitors have shown impressive potential in treatment of pancreatic cancer. Here, the authors present the current status and progress in molecular targeted drug research for pancreatic cancer.

23 Progress in pancreaticojejunostomy technique

GU Jing , CHEN Yijun

2016, 25(9):1357-1362. DOI: 10.3978/j.issn.1005-6947.2016.09.023

[Abstract](142) [HTML](0) [PDF 1.11 M](682)

Abstract:
Pancreaticoduodenectomy has become the first considered surgical method for periampullary cancers and carcinomas of the distal common bile duct and the head of the pancreas, in which, postoperative pancreatic fistula is a common severe complication, and proper selection of pancreaticojejunostomy is curtail for reducing postoperative pancreatic fistula. Although many explorations and improvements for pancreaticojejunostomy technique have been made, pancreatic fistula is still unavoidable. The authors, based on literature review, address the technical development and improvement in pancreaticojejunostomy.

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Volume 25,Issue 9,2016 Table of Contents

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