Volume 29,Issue 3,2020 Table of Contents

1 Technical innovation in robotic pancreaticoduodenectomy

ZHAO Zhiming , WANG Yang , LIU Rong

2020, 29(3):255-259. DOI: 10.7659/j.issn.1005-6947.2020.03.001

[Abstract](508) [HTML](1022) [PDF 1.09 M](1001)

Abstract:
After more than a decade of development, robotic pancreaticoduodenectomy has formed a complete set of relatively mature system, and become one of the mainstream directions of future development. During this period, the surgical procedure experienced a long-term course of exploration, change and innovation, which extended its surgical indications, reduced the postoperative complications, and optimized the process. The authors, based on the experiences from the medical centers all over the world and their own center, address the innovation in the concept and technology of robotic pancreaticoduodenectomy.

2 Neoadjuvant therapy for pancreatic carcinoma

ZOU Caifeng , FU Deliang

2020, 29(3):260-267. DOI: 10.7659/j.issn.1005-6947.2020.03.002

[Abstract](482) [HTML](1165) [PDF 1.15 M](1097)

Abstract:
Pancreatic carcinoma is a highly malignant digestive tumor associated with an extremely poor prognosis, and its early diagnosis and early treatment have always been the study focus areas and difficult tasks for scholars at home and abroad. As the investigations into pancreatic carcinoma deepen, the therapeutic concept of pancreatic carcinoma is also advancing from the pure surgery-first to multidisciplinary collaborative practice model. Neoadjuvant therapy of pancreatic carcinoma is emerging, and it is hoped to effectively prolong the survival time of the patients. However, no consensus has yet been reached with regard to its therapeutic strategy making, regimen selection, treatment cycles or therapeutic effect prediction. Many problems still need to be objectively verified by a series of randomized controlled trials with large sample size, and to the efficacy of neoadjuvant therapy in improving the long-term survival of pancreatic carcinoma patients should be further objectively assessed.

3 Comparison of efficacy and safety of robotic-assisted versus laparoscopic pancreaticoduodenectomy for pancreatic cancer

TU Guangping , SUN Jichun , NIE Wanpin , HU Gui , YU Xiao

2020, 29(3):268-275. DOI: 10.7659/j.issn.1005-6947.2020.03.003

[Abstract](646) [HTML](1127) [PDF 1.76 M](1292)

Abstract:
Background and Aims: Minimally invasive surgery has been rapidly adopted in all surgical specialties, due to its advantages of small incision, reduced trauma and pain as well as quick recovery. The rise of surgical robots brings the minimally invasive surgery into a new era of development, which also conforms to the concept of enhanced recovery after surgery (ERAS). This study was conducted to evaluate the practicability and application value of using da Vinci robot operation system in pancreaticoduodenectomy (PD) for pancreatic cancer.
Methods: The clinical data of 61 patients undergoing minimally invasive PD for pancreatic cancer from January 2016 to May 2019 in the Department of General Surgery of the Third Xiangya Hospital, Central South University were analyzed retrospectively. Of the patients, 24 cases underwent a da Vinci robot-assisted PD (RPD group) and 37 cases underwent the conventional laparoscopic PD (LPD group). The main clinical variables during the perioperative period were compared between the two groups of patients.
Results: There were no significant differences in the preoperative data between the two groups of patients (all P>0.05). In RPD group compared with LPD group, the open conversion rate was significantly decreased (4.2% vs. 8.1%, χ2=4.565, P=0.033), the intraoperative blood loss was significantly reduced (255.0 mL vs. 380.0 mL, Z=–5.813, P<0.001), and the number of resected lymph nodes was significantly elevated (17.0 vs. 11.0, Z=–6.133, P<0.001), but the operative time was significantly prolonged (466.5 min vs. 375.0 min, Z=–6.568, P<0.001). All the surgical margins in both groups were negative reported by postoperative pathology, and there were no significant difference in the pathological results between the two groups (P>0.05); There were no significant differences in the amount of 24-h drainage, and the times to the first postoperative anal gas passage, food intake and ambulation as well as the time for the urinary catheter and wound drainage tube removal between the two groups (all P>0.05); the hospitalization cost of RPD group was significantly higher than that of LPD group (114 154.84 yuan vs. 86 749.59 yuan, Z=–5.863, P<0.001), but the length of hospital stay of RPD group was significantly shorter than that of LPD group (14.0 d vs. 18.0 d, Z=–5.930, P<0.001). Twenty-one cases in RPD group and 33 cases in LPD group were followed up for 22 month, and the 3-year survival rates showed no significant difference between the two groups (20.8% vs. 24.3%, P>0.05).
Conclusion: The assistance of da Vinci robot can improve the quality of PD operation, shorten the recovery time of patients, and is safe and feasible, in line with the concept of ERAS. However, the treatment cost is high, so the family economic situation of patients should be fully considered in choosing this operation.

4 Application of modified Blumgart pancreaticojejunostomy in pancreaticoduodenectomy

LIU Guohua , TAN Xiaoyu , DAI Dong , ZHONG Guohui , LIANG Xiaolu , YANG Junxing , LI Kaifeng

2020, 29(3):276-283. DOI: 10.7659/j.issn.1005-6947.2020.03.004

[Abstract](301) [HTML](1182) [PDF 1.52 M](920)

Abstract:
Background and Aims: The technique and method of pancreaticojejunostomy are important influential factors for the occurrence of pancreatic fistula after pancreaticoduodenectomy (PD). However, none of the pancreaticojejunostomy procedures has a superiority over others in reducing the incidence of postoperative pancreatic fistula so far. This study was conducted to investigate the efficacy and safety using the modified Blumgart pancreaticojejunostomy developed by the authors’ team in PD.
Methods: A retrospective historical control study was performed, which included 55 patients undergoing the conventional invagination pancreaticojejunostomy after PD during August 2014 to January 2017 (conventional group) and 53 patients undergoing the modified Blumgart pancreaticojejunostomy after PD from February 2017 to August 2019 (modified group). The main clinical variables and the incidence rates of postoperative complications were compared between the two groups of patients.
Results: There were no significant differences in preoperative clinical data, total operative time, operative time for pancreaticojejunostomy and intraoperative blood loss as well as the incidence rates of bile leakage and delayed gastric emptying between the two groups (all P>0.05). The incidence rates of postoperative complications that included pancreatic fistula, abdominal hemorrhage and abdominal infection in modified group were significantly lower than those in conventional group (all P<0.05). Biochemical leakage occurred in 4 cases (7.5%) and B/C pancreatic fistula occurred in 3 cases (5.7%) in modified group, while biochemical leakage occurred in 12 cases (21.8%) and B/C pancreatic fistula occurred in 10 cases (18.2%) in conventional group; no abdominal hemorrhage and infection as well as death occurred in modified group, while there were 8 cases of abdominal hemorrhage, 7 cases of abdominal infection and 4 cases of death in traditional group.
Conclusion: Using the modified Blumgart pancreaticojejunostomy can effectively reduce the incidence rates of pancreatic fistula, abdominal bleeding and abdominal infection, so it has certain clinical application value. However, this conclusion still needs to be verified by multi-center prospective clinical studies.

5 A single center experience with 73 cases of laparoscopic pancreaticoduodenectomy

LIN Xiansheng , HUANG Qiang , YANG Ji , SUN Yi , WANG Cheng

2020, 29(3):284-290. DOI: 10.7659/j.issn.1005-6947.2020.03.005

[Abstract](364) [HTML](1111) [PDF 2.39 M](972)

Abstract:
Background and Aims: Pancreaticoduodenectomy (PD) is a complex surgical procedure, which is one of the most difficult procedures in general surgery. With the development of minimally invasive surgical methods, the laparoscopic PD (LPD) has been gradually gaining popularity, and become increasingly mature. This study was conducted to summarize the experience from the authors’ hospital in performing LPD, so as to further improve the efficacy and success rates of this procedure.
Methods: The perioperative clinical data and follow-up results of 73 patients undergoing LPD in the Department of General Surgery, the First Affiliated Hospital of USTC from January 2016 to December 2018 were retrospectively analyzed.
Results: Of the 73 patients, 31 cases were males and 42 cases were females, with an average age of (55.66±11.70) years. The average operative time was (601.3±100.0) min, the average intraoperative blood loss was (448.6±313.3) mL. Postoperative pancreatic fistula occurred in 27 patients (36.9%), including biochemical leakage in 16 cases (21.9%), grade B pancreatic fistula in 6 cases (8.2%) and grade C pancreatic fistula in 5 cases (6.8%); the delayed gastric emptying occurred in 46 patients (63.0%); the postoperative bleeding occurred in 6 patients (8.2%). Four patients (5.4%) underwent postoperative reoperation, and perioperative death occurred in one patient (1.4%). The postoperative pathology diagnosed malignant tumor in 63 patients (86.3%), of whom, 31 cases were cancer of the duodenal papilla, 13 cases were cancer of the lower portion of common bile duct, 14 cases were malignant tumor of the ampulla of Vater, and 5 cases were cancer of the pancreatic head; benign occupying lesion in 10 patients (13.7%), of whom, 6 cases were solid and papillary tumor of the pancreas, 3 cases were mucinous cystadenoma of the pancreas and one case was pancreatic neuroendocrine tumor. Follow-up was performed for 4 to 35 months, with an average of 11.5 month, and no death occurred during this time.
Conclusion: LPD is safe and feasible, the incidence of postoperative complications is within an acceptable level, and it can also meet the standards of radical surgery. With the continuous addition of surgical experience and constant improvement of the laparoscopic devices and apparatus, it can be widely promoted and used.

6 Meta-analysis of efficacy and safety of distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body/tail cancer

HUANG Wanxia , YANG Zhong , WANG Shang , LIU Lu , PENG Lingzhi , ZHANG Yongbin , LIU Tianxiang , QIU Zhisheng , YAO Jibin , DA Mingxu ,

2020, 29(3):291-300. DOI: 10.7659/j.issn.1005-6947.2020.03.006

[Abstract](276) [HTML](1208) [PDF 1.33 M](932)

Abstract:
Background and Aims: Distal pancreatectomy with en bloc celiac axis resection (DP-CAR), a complex surgery, has many potential advantages over the conventional distal pancreatectomy (DP) in the treatment of locally advanced pancreatic body/tail cancer, such as increasing R0 resection rate, reducing pain, improving quality of life, and prolonging survival. However, the clinical efficacy and safety of DP-CAR remain controversial. The purpose of this Meta-analysis was to evaluate the clinical efficacy and safety of DP-CAR in the treatment of locally advanced pancreatic body/tail cancer.
Methods: Literature searches, in both Chinese and English, were performed in several national and international databases from their inception to June 2019 by using relevant search terms. After literature screening strictly according to the inclusion and exclusion criteria, study data extraction and quality assessment of the included studies, Meta-analysis was conducted by RevMan 5.3 software.
Results: A total 13 studies were finally selected, all of which were non-randomized controlled studies, including one prospective study, and 12 retrospective studies; 2 multi-center studies and 11 single-center studies. A total of
1 219 patients were involved, with 237 cases in the DP-CAR group and 982 cases in DP group. The results of Meta-analysis showed that there were no significant differences between DP-CAR group and DP group in 1-, 2- and 3-year survival rates (RR=0.86, 95% CI=0.63–1.18, P=0.36; RR=0.70, 95% CI=0.45–1.10, P=0.12; RR=0.93, 95% CI=0.51–1.70, P=0.82) as well as the incidence of postoperative pancreatic fistula (RR=1.12, 95% CI= 0.92–1.36, P=0.27), while the R0 resection rate was lower (RR=0.78, 95% CI=0.68–0.90, P=0.000 6) and the incidence rates of early postoperative death (RR=4.91, 95% CI=1.90–12.67, P=0.001), reoperation (RR=10.96, 95% CI=3.27–36.74, P=0.000 1), clinically relevant pancreatic fistula (RR=1.57, 95% CI=1.19–2.08, P=0.002) and delayed gastric emptying (RR=2.78, 95% CI=1.33–5.81, P=0.007) were significantly higher in DP-CAR group than those in DP group, further, the operative time was longer (MD=91.98, 95% CI=60.63–123.34, P<0.000 01) and estimated blood loss was greater (MD=275.33, 95% CI=135.95–414.71, P=0.000 1) in DP-CAR group than those in DP group.
Conclusion: DP-CAR offers no significant survival benefit for patients with locally advanced pancreatic body/tail cancer, in addition, it will increase the mortality and reoperation rates as well as the incidence of postoperative complication. So, this procedure should be chosen with caution.

7 Meta-analysis of the efficacy of preoperative immunonutrition in patients undergoing pancreaticoduodenectomy

LIU Xiaoyan , CHAI Changpeng , ZHOU Wence ,

2020, 29(3):301-309. DOI: 10.7659/j.issn.1005-6947.2020.03.007

[Abstract](558) [HTML](970) [PDF 1.08 M](1089)

Abstract:
Background and Aims: Immunonutrition can improve the body's nutritional status, regulate the body's immune system, control the excessive inflammatory response in the body, and speed patients' postoperative recovery. However, there is no final conclusion about the influences of preoperative immunonutrition on patients undergoing pancreatoduodenectomy (PD). Therefore, this study systematically evaluated the efficacy of preoperative immunonutrition in patients undergoing PD.
Methods: The randomized controlled trials (RCTs) concerning PD patients receiving preoperative immunonutrition were collected by a computer-based search in several national and international databases from the time of inception to July 2019. After literature review and screening, data extraction and assessment of risk of bias of the selected studies by two reviewers independently, Meta-analysis was performed by using RevMan 5.3 software.
Results: A total of 11 RCTs were included, involving 614 patients, with 310 in study group (receiving preoperative immunonutrition support) and 304 in control group (receiving conventional nutrition support before operation). The results of the Meta-analysis showed that there were no significant differences in operative time, intraoperative blood loss and number of cases requiring intraoperative blood transfusion between the two groups (all P>0.05); the overall incidence of infective complications in study group was significantly lower than that in control group (OR=0.37, 95% CI=0.23–0.59, P<0.000 1), which was mainly driven by the significantly low incidence of wound infection (OR=0.51, 95% CI=0.29–0.89, P=0.02); in study group versus control group, no significant difference was noted in the overall incidence of non-infective complications (OR=0.89, 95% CI=0.67–1.18, P=0.41) as well as the incidence of each specific non-infective complication (all P>0.05); the length of hospital stay of study group was significantly shorter than that of control group (MD=–1.91, 95% CI=–3.21––0.60, P=0.004).
Conclusion: The current evidence indicates that the preoperative use of immunonutrition in PD patients is beneficial to reduce the occurrence of postoperative infective complications, shorten the length of hospital stay, and promote postoperative recovery. However, due to limitations of number and quality of the included studies, the above conclusions need to be verified by more high-quality studies.

8 Clinical value of preoperative albumin-bilirubin score and its combination with CA19-9 as prognostic indicators for pancreatic cancer patients

FAN Hongxing , NI Jianxun , BO Biao , GAO Xian , FANG Qilou

2020, 29(3):310-316. DOI: 10.7659/j.issn.1005-6947.2020.03.008

[Abstract](330) [HTML](1257) [PDF 1.15 M](901)

Abstract:
Background and Aims: The albumin-bilirubin (ALBI) score is used for assessing the severity of liver dysfunction in patients with hepatocellular carcinoma and however, recent studies demonstrated that it may also have certain relevance with the prognosis of other malignant tumors. Therefore, this study was conducted to investigate the clinical value of using ALBI score or its combination with the commonly used pancreatic cancer marker carbohydrate antigen 19-9 (CA19-9) as the prognostic index for pancreatic cancer patients.
Methods: The clinical data of 97 patients undergoing pancreatic cancer resection in the Department of General Surgery of Fuxin Mining General Hospital of Liaoning Health Industry Group from January 2010 to November 2014 were retrospectively analyzed. All these patients underwent determination of the serum levels of albumin, total bilirubin and CA19-9 on the day before operation. The correlation between serum albumin level and total bilirubin concentration in the patients, the relations of CA19-9 level with the clinicopathologic factors and ALBI score of the patients, as well as the associations of ALBI score and CA19-9 level with the prognosis of the patients were analyzed.
Results: There was a significant correlation between serum albumin level and total bilirubin concentration in the pancreatic cancer patients (r=0.45, P=0.018). The ALBI score was significant related to whether or not the patients underwent preoperative biliary drainage due to biliary obstruction (P=0.008), but irrelevant to the CA19-9 level and all other clinicopathologic factors of the patients (all P>0.05). The 5-year survival rate in patients of high ALBI group was significantly lower than that in patients of low ALBI group (22.2% vs. 42.3%, P=0.036), and in patients of high CA19-9 group was significantly lower than that in patients of low CA19-9 group (24.1% vs. 44.2%, P=0.035); the results of combined analysis showed that the 5-year survival rates in patients with both high ALBI and high CA19-9 (double-high group), high ALBI and low CA19-9 (high ALBI group), low ALBI and high CA19-9 (high CA19-9 group) and both low ALBI and low CA19-9 (double-low group) were 12.0%, 35.0%, 34.5% and 52.2% respectively; the 5-year survival rate of double-high group was significantly lower than that of either single-high group (high ALBI group plus high CA19-9 group) or double-low group (12.0% vs. 34.7%, P=0.038; 12.0% vs. 52.2%, P=0.003), while no significant difference was noted between the latter two groups (P=0.159). The results of multivariate analysis showed that the combination of ALBI score and CA19-9 (P=0.009) along with the lymph node metastasis (P=0.012) were independent risk factors for the prognosis of pancreatic cancer patients.
Conclusion: There is a certain relevance between the ALBI score and CA19-9 level in pancreatic cancer patients, and the combined parameter of ALBI score and CA19-9 level can be used as an independent prognostic factor for estimating the outcomes of pancreatic cancer patients. Those with concomitant high ALBI score and high CA19-9 level may face an unfavorable result.

9 Construction and evaluation of a new animal model of hypertriglyceridemia acute pancreatitis in rats

REN Ruiyu , CHEN Yao , ZHOU Huiqin , DING Yongkai , ZHOU Yu , CHEN Chen , WANG Weixing

2020, 29(3):317-323. DOI: 10.7659/j.issn.1005-6947.2020.03.009

[Abstract](330) [HTML](1145) [PDF 1.81 M](1334)

Abstract:
Background and Aims: At present, in the research of hypertriglyceridemia acute pancreatitis (HTG-AP), the methods for generating animal models are diverse, and the models are also difficult to construct. Therefore, this study was conducted to develop a new method for establishing a rat HTG-AP model by using the hyperlipidemia inducing agent poloxamer-407 (P-407) combined with L-arginine.
Methods: Seventy-two male SD rats were equally randomized into normal control group, and low dose P-407
(0.12 g/kg), medium P-407 dose (0.25 g/kg) and high P-407 dose (0.50 g/kg) group. Rats in normal control group did not receive any treatment, and those in the other 3 groups underwent intraperitoneal injection of respective doses of P-407 once per day to induce hyperlipidemia. Six rats in each group were randomly selected on 1 week, 2 and 4 weeks later respectively, and underwent intraperitoneal injection of 20% L-arginine (2.5g/kg) twice (a 1-h time interval) to induce acute pancreatitis, and were sacrificed 24 h later, and then the blood samples were taken for measurement of the serum levels of liver and renal function parameters as well as the serum levels of triglyceride (TG), total cholesterol (TC), amylase (AMY) and lipase (LIPA), and the pancreatic tissues were harvested for observation and scoring of the pathological changes of pancreas.
Results: In each P-407 dose group compared with normal control group, the serum levels of liver and renal function parameters showed no significant changes at each time point (all P>0.05); the serum levels of TG and TC levels were significantly increased at each time point with a time- and dose-dependent manner (all P<0.05), in which, the TG level in low P-407 dose group did not reach a blood lipid standard of HTG-AP (TG>11.3 mmol/L) at each time point, while the TG level in high and medium P-407 dose group reached the blood lipid standard of HTG-AP from 1 week and 2 weeks after the experiment, respectively. In each P-407 dose group compared with normal control group, the serum levels AMY and LIPA were all significantly increased and the scores for pancreatic pathological injury were all significantly elevated, and all these effects presented a time- and dose-dependent manner (all P<0.05).
Conclusion: Using a suitable dose of P-407 (0.25-0.50 g/kg) combined with 20% L-arginine (2.5 g/kg) can successfully construct a stable rat HTG-AP model within a short period of time (1 week to 2 weeks). This model is easy to be replicated with good reproducibility, and can provide a convenient tool for studies in the relevant fields.

10 Bioinformatics analysis of expression of UDP-glucose 6-dehydrogenase in pancreatic cancer and its significance

LI Wenjun , REN Longfei , ZHAO Suyue , WANG Qianhe , ZHU Kexiang

2020, 29(3):324-332. DOI: 10.7659/j.issn.1005-6947.2020.03.010

[Abstract](641) [HTML](1078) [PDF 1.51 M](957)

Abstract:
Background and Aims: UDP-glucose 6-dehydrogenase (UGDH) is a metabolic enzyme that converts UDP-glucose to UDP-glucuronic acid, it affects the tumor invasion and drug resistance by participating in the biosynthesis of glycosaminoglycan in tumor tissues. A number of studies have shown that UGDH gene is involved in the occurrence and development of a variety of cancers. However, there is still no research concerning the UGDH gene in pancreatic cancer, so this study was conducted to investigate the UGDH gene expression in pancreatic cancer and its significance by bioinformatics approaches.
Methods: The differential expression of UGDH gene in pancreatic cancer tissue was analyzed in 4 data sets of the Oncomine database. Survival analysis was performed based on the gene expression profiles and survival data of the pancreatic cancer in TCGA database. Based on UALCAN database, the correlation between the expression of UGDH gene and other genes in pancreatic cancer in TCGA was analyzed, and the genes with significant positive and negative correlation with UGDH gene were obtained by Pearson coefficient method, and then, GO and KEGG pathway enrichment analyses were performed, respectively. Based on the annotation of the whole human genome from HGNC database, the expression profile of all mRNA in pancreatic cancer was extracted, and then the gene base enrichment analysis of UGDH gene in pancreatic cancer was carried out by using GSEA analysis software; the monogenic PPI network involving the UGDH gene was constructed by GeneMANIA, and the genes appeared in the network were further enriched by Metascape, and then, the critical subnetworks were identified by Cytoscape MCODE plug-in.
Results: UGDH gene expression was significantly up-regulated in pancreatic cancer samples, and the overall survival rate was significantly higher and survival time was significantly longer in patients with low UGDH gene expression than those in patients with high UGDH gene expression (all P<0.05). GO enrichment analysis found that UGDH and its co-expressed genes were enriched in the endomembrane system organization, RNA localization, proteasomal protein catabolic process, nucleocytoplasmic transport, nucleic acid transport and other biological processes related to cancer. KEGG enrichment analysis showed that the differential expressed genes were mainly enriched in cancer-related pathways such as protein processing in endoplasmic reticulum, autophagy-animal, ubiquitin mediated proteolysis, protein export, spliceosome, RNA transport, mRNA surveillance pathway, viral carcinogenesis, long-term depression, colorectal cancer, N-Glycan biosynthesis, pancreatic cancer and sphingolipid signaling pathway, proteoglycans in cancer, renal cell carcinoma, human cytomegalovirus infection, hepatitis B. GSEA analysis showed the enriched cancer-related pathways such as ubiquitin mediated proteolysis, amino sugar and nucleotide sugar metabolism, aminoacyl-tRNA biosynthesis, oocyte meiosis, renal cell carcinoma, basic transcription factors, sphingolipid metabolism, ErbB signaling pathways, adherens junction, chronic myeloid leukemia, RIG-I like receptor signaling pathway, GNRH signaling pathway, insulin signaling pathway, endometrial cancer, glioma, neurotrophin signaling pathway, MAPK signaling pathway, pancreatic cancer. PPI prediction and key sub-network analysis revealed that HGS, UBE2V1, MAT2A and SUMO1 played important roles in the interaction network.
Conclusion: UGDH gene expression is up-regulated in pancreatic cancer tissue, and is closely related to the occurrence and development as well as the prognosis of pancreatic cancer. The results of this study may provide important information and basis for future studies on the pathogenesis and molecular target therapy of pancreatic cancer.

11 Undifferentiated pleomorphic sarcoma of pancreas: case report and literature review

WANG Zihang , MENG Xingkai , ZHANG Junjing

2020, 29(3):333-340. DOI: 10.7659/j.issn.1005-6947.2020.03.011

[Abstract](1036) [HTML](1398) [PDF 2.13 M](1091)

Abstract:
Background and Aims: Undifferentiated pleomorphic sarcoma (UPS), previously known as malignant fibrous histiocytoma (MFH), is a malignant tumor of mesenchymal origin, accounting for more than 20% of all soft tissue sarcomas, most of which occur in the limbs, body trunk and retroperitoneal space. The occurrence of UPS in the pancreas is extremely rare. Although there are some reports at home and abroad, most of them are presented as individual case report, and the data analysis of larger series of patients are scarce. This article was written to discuss the clinical characteristics, diagnosis and treatment as well as the prognosis of this condition through analyzing one patient case of pancreatic UPS treated by the author’s team combined with the literature data.
Methods: The clinical data of one patient with pancreatic UPS diagnosed and treated in the Department of Hepatobiliary Surgery of the Affiliated Hospital of Inner Mongolia Medical University was retrospectively analyzed. Meanwhile, a search of the relevant literature from the national and international databases was performed. Then, a pooled analysis of the same medical cases was conducted.
Results: There a total of 32 patients (including our case and 31 cases reported in the literature) were enrolled in the study. Of the patients, 20 cases were males and 12 case were females, with a median age of 54.6 (22–74) years. The pathological types were classified as giant cell tumor in 9 cases, myxoid tumor in 5 cases, and pleomorphic tumor in 18 cases. The tumors were located in the head of the pancreas in 13 cases, in the body and tail of the pancreas in 12 cases, in the body of the pancreas in 3 cases, in the tail of the pancreas in 2 cases and in whole pancreas in 2 cases. Preoperative diagnosis was pancreatic cancer in 8 cases of, pancreatic tumor and space occupying lesion in 6 cases, pseudocyst in 4 cases, cystadenoma in 4 cases, pancreatic tumor in 3 cases of, and interstitial tumor, fibrosarcoma, inflammatory lesion in one case each and unavailable in 4 cases. The clinical manifestations included rapidly progressive enlargement of soft tissue lump, frequently accompanied with pressure symptoms or nausea and vomiting, epigastric discomfort, abdominal distension, weight loss or jaundice. The correct diagnosis was made in none of the patients. All the 32 patients underwent surgical treatment, perioperative death occurred in one case, and the overall survival time is 15.3 months.
Conclusion: The pancreatic UPS is a highly malignant tumor with no specific clinical manifestations, high likelihood of metastasis and recurrence, and dismal prognosis. Early and complete resection of the tumor to obtain R0 resection is essential for surgical treatment. However, even if extensive resection or radical resection is performed in some cases, local tumor recurrence or distant metastasis still cannot be avoided, due to the special biohistological characteristics of pancreatic UPS. Postoperative radiotherapy and chemotherapy may probably improve survival of the patients.

12 Clinical value of immature granulocyte percentage in early evaluation of severe acute pancreatitis

HOU Wei , LI Lianqian , WU Wenlong , XIAO Bowen

2020, 29(3):341-347. DOI: 10.7659/j.issn.1005-6947.2020.03.012

[Abstract](278) [HTML](1226) [PDF 1.08 M](1081)

Abstract:
Background and Aims: Severe acute pancreatitis (SAP) is a dangerous acute abdominal disorder, characterized by rapid progression, numerous complications and high mortality. Early detection of SAP may helpful for guiding the clinical treatment and improving the prognosis of the patients. Immature granulocyte percentage (IG%) is an emerging inflammatory indicator, which may display an obvious change in the early stage of diseases. Considering the inflammatory indicators play crucial roles in the development of SAP, this study was to conducted to evaluate the clinical value of IG% in the early detection of SAP.
Methods: The clinical data of 521 patients diagnosed as acute pancreatitis (AP) according to the guidelines from January 2010 to October 2019 were retrospectively analyzed. Of the patients, 63 cases were SAP (SAP group) and 458 cases were mild or moderately severe AP (non-SAP group). The clinical features and the variables that included IG%, white blood cell (WBC) count, neutrophil to lymphocyte ratio (NLR), C-reactive protein (CRP) and amylase level were compared between the two groups of patients. The diagnostic efficiency of each inflammatory indicator for SAP was determined by receiver operating characteristic curve (ROC) analysis.
Results: The mortality rate in SAP group was 2.2% (18/63) and in non-SAP group was 28.6% (10/458); the patients was older, and the proportions of cases requiring ICU admission and surgical intervention were higher and the length of hospital stay was longer in SAP group than those in non-SAP group (all P<0.05). The levels of IG%, WBC, NLR and CRP in SAP group were significantly higher than those in non-SAP group (all P<0.005), but there was no significant difference in serum the amylase levels between the two groups (P=0.163). The results of ROC analysis showed that the diagnostic powers of IG%, WBC, NLR and CRP for SAP were all had significance (all P<0.005); the area under the curve (AUC) of IG% in predicting SAP was 0.973, with a sensitivity of 100% and specificity of 93.8% at the optimal cut-off value of 0.9, which was superior to WBC (AUC: 0.665, sensitivity: 66.6%, specificity: 87.6%), NLR (AUC: 0.752, sensitivity: 73.3%, specificity: 76.5%) and CRP (AUC: 0.802, sensitivity: 100%, specificity: 54.9%).
Conclusion: The IG% value in the blood routine greater than 0.9 may be an early indicator for pancreatic necrosis. Compare to traditional inflammatory indicators, IG% is more effective and reliable predictor of SAP.

13 Analysis of risk factors for healthcare-associated complicated intra-abdominal infections in adults

JIANG Huaye , HUANG Xun , ZUO Shuangyan , LIU Yao , WU Yayun

2020, 29(3):348-354. DOI: 10.7659/j.issn.1005-6947.2020.03.013

[Abstract](601) [HTML](1191) [PDF 1.07 M](1010)

Abstract:
Background and Aims: Complicated intra-abdominal infection (cIAI) is the second most common infection after surgery. Despite the increasing improvement of the diagnostic and treatment techniques, the mortality rate of cIAI is still high. The cIAI developed during hospitalization not only endangers the patients’ lives, but also exerts a negative impact on their long-term prognosis. This study was conducted to investigate the risk factors for healthcare-associated cIAI (HA-cIAI) in adults, so as to provide basis for implementation of appropriate intervention measures in clinical practice, and thereby reduce the incidence of HA-cIAI.
Methods: The clinical data of 359 adult patients whose ascitic fluid samples were collected and positive for rapid aerobic bacterial culture during hospitalization and with clinical diagnosis of cIAI from November 2011 to July 2016 in Xiangya Hospital of Central South University were retrospectively analyzed. Of the patients, 143 cases were community-acquired cIAI (CA-cIAI group) and 216 cases were HA-cIAI group (HA-cIAI group). The general conditions, treatments and laboratory indicators of the two groups of patients were compared, and the risk factors for HA-cIAI were analyzed.
Results: Compared with CA-cIAI group, the patients in HA-cIAI group showed a high proportion of cases with age ≥60, prolonged average length of hospital stay, high proportions of cases with abdominal malignancy and undergoing abdominal surgery during hospitalization, low hemoglobin and procalcitonin levels and high alamine aminotransferase level (all P<0.05). Among patients undergoing abdominal surgery during hospitalization, the proportions of the surgery duration ≥3 h, intraoperative blood loss ≥200 mL, the retention time of abdominal drainage tube ≥10 d, the indwelling urethral catheter and its retention time ≥7 d, as well as preoperative use of antibiotics in HA-cIAI group were significantly higher than those in CA-cIAI group (all P<0.05). The results of Logistic regression analysis showed that the length of hospitalization ≥15 d (OR=6.946, 95% CI=3.786–12.743, P<0.05) and abdominal malignancy (OR=2.880, 95% CI=1.538–5.390, P<0.05) were independent risk factors for HA-cIAI.
Conclusion: Middle and old age, abdominal malignancy, long hospital stay and surgery duration, large amount of intraoperative bleeding, long retention time of abdominal drainage tube, indwelling urethral catheter and long retention time of urethral catheter, and use of antibiotics before operation, especially the length of hospitalization ≥15 d and abdominal malignancy are the high-risk factors for HA-cIAI. For patients with above factors, effective preventive measures should be taken according to the specific condition, to prevent the occurrence of HA-cIAI.

14 Current situation of diagnosis and treatment of diabetic foot patients before entering grade A tertiary hospitals with specialized services and the influential factors

ZHOU Lihuan , ZHOU Qiuhong , XU Jingcan , PENG Min , ZHAO Nan

2020, 29(3):355-362. DOI: 10.7659/j.issn.1005-6947.2020.03.014

[Abstract](228) [HTML](876) [PDF 1.09 M](819)

Abstract:
Background and Aims: Diabetic foot (DF) is one of the major causes of disability and death among patients with diabetes. Early diagnosis and standardized treatment of DF can not only increase the efficacy of treatment and accelerate ulcer healing, but also are the effective means for limb salvage and reducing medical costs. This study was conducted to investigate the current status of diagnosis and treatment of DF and the associated factors for the DF patients before referral to a grade A tertiary hospital with specialized multidisciplinary team for dealing with DF, so as to provide the relevant basis for the standardized diagnosis and treatment of this condition.
Methods: Using a random cluster sampling method design, a total of 326 patients with Wagner's grade 1-5 DF were selected during October to November 2017 from 13 grade A tertiary hospitals with specialized DF treatment center in Hunan, Zhejiang, Shanghai, Sichuan, Guangdong, Hebei, Heilongjiang and Macao, respectively, on whom, the questionnaire survey and foot examination were performed. The selection of wound cleaning fluid and the type of wound medication were used as the assessment criteria to evaluate the normalization of treatment before admission to grade A tertiary hospitals, and the factors that affect the standardization of treatment were analyzed.
Results: Among the 236 DF patients, the misdiagnosis rate was 22.7%, and the rate of non-standard treatment was 72.7%. The results of univariate analysis showed that the degree of treatment standardization was significantly related to the person who performed the debridement, the level of the hospital where the patients were admitted, the person who changed the dressing, the location of the prehospital diagnosis and treatment, the number of complications and the site where the debridement was performed (all P<0.05). The results of Logistic regression analysis revealed that the hospital level and wound dressing person were independent influential factors for the standard treatment rate of DF (both P<0.05), in which, the standard treatment rate of DF in tertiary hospital was 6.707 times higher than that in primary hospital, and was also significantly better than that in secondary hospital; the standard treatment rate of DF with wound dressing performed by wound/ostomy therapists was 24.117 times higher than that performed by patient’s patients themselves, and was also superior to those performed by doctors and nurses.
Conclusion: There are many misdiagnosis and non-standard treatment in DF patients before entering a grade A tertiary hospital with a specialized multidisciplinary team for DF. Therefore, the training on the standardized diagnosis and treatment of DF among medical staff in primary hospitals should be further strengthened and particularly, more attention should be paid to the training of the wound/ostomy therapists; the two-way referral system for DF patients in primary medical institutions and tertiary hospitals should be improved; the patients should be encouraged to seek medical assistance to reduce the occurrence of misdiagnosis and non-standard diagnosis and treatment.

15 Research progress of influence of ERCC1 gene expression on the efficacy of platinum-based chemotherapy for pancreatic cancer

HE Tengjun , LI Jiang , ZHAO Zhuoyu , CAI Xiaobei

2020, 29(3):363-368. DOI: 10.7659/j.issn.1005-6947.2020.03.015

[Abstract](786) [HTML](1025) [PDF 1.07 M](1034)

Abstract:
Pancreatic cancer has an insidious onset but rapid progress. Most patients are in advanced stage at the time of admission to the hospital. More than half of the patients still relapse early even after a radical resection, with an extremely low 5-year survival rate. Although systemic chemotherapy can improve the overall survival rate of pancreatic cancer patients, its efficacy is still worse than inpatients with other adenocarcinomas. Platinum compounds are the main agents for chemotherapy of pancreatic cancer, to which, resistance may arise in tumor cells with high expression of ERCC1, causing primary drug resistance of the tumor to the chemotherapy. Whether the sensitivity of the pancreatic cancer cells to platinum-based chemotherapy regimen can be predicted by determining the their ERCC1 expression levels, and whether their response to chemotherapy can be improved by regulating the ERCC1 expression may be the breakthrough for increasing the chemotherapy efficacy of pancreatic cancer. At present, the researches in this field are still in their infancy. Here, the authors briefly review the relevant research progress, so as to provide assistance for future studies.

16 Functional heterogeneity of pancreatic stellate cells and their role in the field of exosomes: recent research advances

CAI Ming , LIN Xiansheng , SHAO Feng , LIU Zhen , MENG Futao , HUANG Qiang

2020, 29(3):369-376. DOI: 10.7659/j.issn.1005-6947.2020.03.016

[Abstract](654) [HTML](1205) [PDF 1.18 M](1360)

Abstract:
Pancreatic stellate cells (PSCs) are a type of pluripotent cells located around the pancreatic lobules and acinar units. PSCs are in a quiescent state in the normal pancreas. Under the stimulation of various pathophysiological conditions, PSCs will be activated, and activated PSCs can be transformed into an activated phenotype similar to myofibroblasts. Compared with the quiescent state, activated PSCs can proliferate and actively migrate, secrete a large amount of extracellular matrix, and participate in the regulation of the progression of the pancreatic cancer and chronic pancreatitis acting as an important component of the microenvironment of the diseased pancreas. At the same time, a large number of studies have clarified that PSCs have functional heterogeneity. Because of their cell markers and functional differences, they are divided into different cell subgroups, which can regulate the occurrence and development of pancreatic cancer alone or in collaboration. The exosomes derived from PSCs can promote the growth, proliferation and invasion of pancreatic cancer cells through information transfer and material exchange between cells, and thereby regulate the development of pancreatic cancer. In chronic pancreatitis, activated PSCs and their derived exosomes are important components that initiate and promote pancreatic fibrosis. Therefore, the research on the functional heterogeneity of PSCs and the derived exosomes may provide new strategies and methods for the treatment of pancreatic diseases.

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Volume 29,Issue 3,2020 Table of Contents

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