Volume 31,Issue 9,2022 Table of Contents

1 Research progress of critical acute pancreatitis

SHEN Dingcheng , HUANG Gengwen

2022, 31(9):1129-1134. DOI: 10.7659/j.issn.1005-6947.2022.09.001

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Critical acute pancreatitis (CAP) is a type of acute pancreatitis (AP) characterized by the concurrence of both persistent organ failure and infected pancreatic necrosis. Its proportion in AP is relatively low. However, it is always complicated with extremely adverse clinical outcomes and high risk of mortality and morbidity. CAP has been supposed to be the most ominous severity category of AP. Due to few clinical studies focusing on CAP worldwide, the knowledge and clinical experience of CAP are still insufficient. Through literature review and summary of the practical experience, the authors interpret and discuss the progress of CAP, to attract further attention of the pancreatic surgeons, continuously improve the diagnosis and treatment measures and reduce the mortality rate of CAP.

2 Meta-analysis of influence of sarcopenia on clinical outcomes after pancreaticoduodenectomy

MA Jindong , JIAO Xiangfei , CAI Tingting , JI Haibin , CHEN Qiangpu

2022, 31(9):1135-1144. DOI: 10.7659/j.issn.1005-6947.2022.09.002

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Background and Aims Sarcopenia can lead to an increased risk of adverse events such as limb dysfunction, decreased quality of life, and death. Studies on the influences of sarcopenia on patients undergoing pancreaticoduodenectomy (PD) are scarce and the findings are inconsistent. This study was conducted to systematically evaluate the effects of sarcopenia on postoperative clinical outcomes in patients undergoing PD to improve clinical outcomes through effective interventions.Methods Relevant literature was searched using PubMed, Embase, Cochrane Library, CNKI, VIP, and Wanfang databases from the time of database inception to June 1, 2022. After literature screening, information extraction and evaluation of the quality and risk of bias of the included studies by two independent investigators, the data were analyzed using RevMan 5.3 software.Results Fourteen studies with a total of 2 198 patients were included, with 737 patients in the sarcopenic group and 1 461 patients in the non-sarcopenic group, all of which were cohort studies. Meta-analysis showed that there were no significant differences in operative time and incidence rates of wound infection, urinary tract infection, biliary fistula, and postoperative bleeding between the two groups (all P>0.05); in the sarcopenic group compared with the non-sarcopenic group, the preoperative BMI value (WMD=-1.22, 95% CI=-1.82-0.62, P<0.001) and preoperative albumin level (WMD=-0.30, 95% CI=-0.41-0.19, P<0.001) were lower, intraoperative blood loss was higher (WMD=88.12, 95% CI=6.94-169.31, P<0.05), the incidence rates of overall postoperative complications (OR=3.53, 95% CI=2.52-4.94, P<0.001), complications graded Clavien-Dindo ≥3 (OR=1.57, 95% CI=1.17-2.12, P=0.003), bacteremia (OR=4.46, 95% CI=1.42-13.98, P=0.01), pneumonia (OR=2.07, 95% CI=1.31-3.25, P=0.002), and pancreatic fistula (OR=1.34, 95% CI=1.05-1.72, P=0.02) were higher; the hospital stay was prolonged (OR=3.18, 95% CI=1.97-4.39, P<0.001), and mortality was increased (OR=3.17，95% CI=1.55-6.50，P=0.002).Conclusion There is a high proportion of patients undergoing PD with preoperative comorbid sarcopenia. The concomitant sarcopenia has a detrimental influence on the clinical outcomes of patients, as evidenced by increased complication and mortality rates and lengthened hospital stay.

3 Application of laparoscopic pancreaticoduodenectomy guided by membrane anatomy: a report of 17 cases

TAN Shengqiang , WEI Min , LIU Zhen , WU Yongrong , JIANG Zhijun , LU Yi , CAI Jingming , CHEN Limin , ZHOU Zheng

2022, 31(9):1145-1153. DOI: 10.7659/j.issn.1005-6947.2022.09.003

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Background and Aims Laparoscopic pancreaticoduodenectomy (LPD) has developed rapidly in recent years. However, the complexity of the essential techniques such as dissection, separation, and anastomosis involved in this operation limits its widespread application. Based on the successful application of the membrane anatomy concept in the field of gastrointestinal surgery, the author's team preliminarily explored the clinical application value of the membrane anatomy concept in LPD.Methods The clinicopathologic data of 17 patients with pancreatic head and ampullary tumors who underwent LPD based on the concept of membrane anatomy from March to September 2021 in Liuzhou People's Hospital Affiliated with Guangxi Medical University were retrospectively collected. The perioperative conditions and short-term outcomes of the patients were analyzed.Results Among the 17 patients, 10 cases were males and 7 cases were females, with a median age of 58 (42-76) years; the preoperative body mass index was (22.95±2.73) kg/m², CA19-9 value was (147.59±23.04) U/mL, and total bilirubin level was (124.50±26.26) μmol/L. LPD was successfully completed in all 17 patients. The average total operative time was (324±58) min, the median operative time before digestive tract reconstruction was 160 (120-320) min, the average bleeding volume was (353±192) mL, and the size of the lesion was (2.75±0.21) cm. There were 4 cases of duodenal papillary carcinoma, 7 cases of pancreatic cancer, 5 cases of ampullary cancer of the pancreaticobiliary subtype, and 1 case of duodenal neuroendocrine tumor; the number of harvested lymph nodes was 12 (5-17), and the number of positive lymph nodes was 7 (0-11). After the operation, biochemical leakage occurred in 2 cases, and no grade B or C pancreatic fistula occurred; delayed gastric emptying occurred in one case who resumed a solid diet within postoperative 10 d after replacing the gastric tube and symptomatic treatment; no abdominal infection and bleeding occurred; The postoperative hospitalization time of 17 patients was 11(9-21) d; No death occurred within 30 d after operation. All the 17 patients were followed up for 3.0-9.0 months with a median follow-up time of 5.7 months. No death and recurrence occurred.Conclusion The LPD based on the concept of membrane anatomy has less bleeding during the operation, and is helpful for keeping the clear vision of the surgical field, following the "tumor free principle" of surgery, reducing the occurrence of surgical complications, and shortening the length of hospitalization of patients, which makes the operation safe and feasible. Its short-term effect is satisfactory, and the long-term effect needs to be further observed. To a certain extent, it is worth to be widely applied and popularized.

4 A report of 4 cases of 3D laparoscopic duodenum-preserving pancreatic head resection under fluorescence imaging navigation (with video)

WANG Wener , SONG Xin

2022, 31(9):1154-1161. DOI: 10.7659/j.issn.1005-6947.2022.09.004

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Background and Aims Duodenum-preserving pancreatic head resection (DPPHR) is a commonly used option for benign or low-grade malignant space-occupying lesions of the head of the pancreas. Despite advances in laparoscopic techniques, performing this procedure under traditional laparoscopic approaches is still considerably challenging. In recent years, the emergence of 3D laparoscopic techniques overcomes the shortcomings of traditional laparoscopic methods and makes laparoscopic surgery more precise and safer. Here, the authors summarize the experience in 4 cases undergoing 3D laparoscopic DPPHR guided by fluorescence imaging, so as to provide a reference for the application and promotion of this technique.Methods The clinical data of 4 patients who underwent 3D laparoscopic laparoscopic DPPHR under fluorescence imaging navigation from August 2019 to May 2021 in the People's Hospital of Xiangxi Tujia and Miao Autonomous Prefecture were analyzed retrospectively.Results The 3D laparoscopic DPPHR under fluorescence imaging navigation was successfully completed in all 4 patients. The operative time was 370-510 min, and the blood loss was 80-300 mL, with no transfusion requirements of red blood cells and plasma. After the operation, one patient developed delayed gastric emptying, which was resolved by inserting a nasojejunal nutrition tube, 2 patients developed grade A biochemical leakage, and there were no complications such as duodenal perforation, postoperative bile leakage, postoperative bleeding, and secondary operation. All 4 patients were followed up for 3-24 months and recovered well.Conclusion Performing 3D laparoscopic DPPHR guided by fluorescence imaging is safe and feasible with the appropriate selection of patients in an experienced pancreatic surgery center.

5 Construction and application of online dynamic nomogram for predicting prognosis of pancreatic cancer patients

SHI Huaqing , CHAI Changpeng , CHEN Zhou , DONG Shi , HE Ru , QIN Zishun , ZHOU Wence

2022, 31(9):1162-1172. DOI: 10.7659/j.issn.1005-6947.2022.09.005

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Background and Aims Pancreatic cancer is a highly aggressive malignancy and patients with pancreatic cancer will face a dismal prognosis. Unlike other cancers, the incidence of pancreatic cancer has continued to increase over the past few years with little improvement in survival rates. The prognostic indicators of the TNM staging system currently used in clinical practice to assess the prognosis of patients are relatively limited. Therefore, this study was designed to construct a dynamic online nomogram for clinical prediction of prognosis of pancreatic cancer patients, so as to provide guidance for clinical individualized treatment.Methods Information of patients with pancreatic cancer from 2000 to 2018 was extracted from the SEER database, and patients were randomly allocated to the training cohort and validation cohort at a ratio of 7∶3. Univariate and multivariate Cox regression analyses were used to identify the prognostic risk factors, and dynamic online nomogram was constructed using R software. The C-index, area under the curve (AUC) of time-dependent ROC curves, calibration plot, and decision curve analysis (DCA) was used to assess the clinical utility of the nomogram. Finally, the pancreatic cancer patients were divided into high-risk and low-risk groups according to the nomogram, and the prognostic results of the two groups of patients were compared by Kaplan-Meier survival curves.Results A total of 12 175 patients with pancreatic cancer were screened. Age, degree of tumor differentiation, primary tumor site, T stage, N stage, M stage, surgery, chemotherapy, and tumor size were independent influencing factors for OS (all P<0.05). In the training cohort, the C-index for the OS nomogram was 0.759 (95% CI=0.745-0.772), and the AUC values for predicting the 1-, 3- and 5-year OS were 0.828, 0.842, and 0.849, respectively. In the validation cohort, the C-index was 0.756 (95% CI=0.735-0.776), and the AUC values for predicting the 1-, 3- and 5-year OS were 0.820, 0.831, and 0.842, respectively. The calibration plot and DCA curves demonstrated good prediction performance of the model in both the training and validation cohorts. Results of Kaplan-Meier survival curves showed that the overall OS of patients in the low-risk group was superior to that of patients in the high-risk group in either the validation cohort or training cohort (both P<0.05).Conclusion The established dynamic online nomogram has a good prediction efficiency and it is helpful for comprehensive prediction of the prognosis of pancreatic cancer patients by a personalized combination of the actual clinical situation of patients. Moreover, the nomogram may have a better clinical application value than the TNM staging system.

6 Efficacy analysis of mini-incision access combined with endoscopic pancreatic necrosectomy for infected pancreatic necrosis: a report of 9 cases

BU Hao , WU Haoran , YE Jinsong , LIU Youyuan , LI Hui , ZHAO Kai , LIU Shengjun

2022, 31(9):1173-1181. DOI: 10.7659/j.issn.1005-6947.2022.09.006

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Background and Aims In recent years, comprehensive treatment through multidisciplinary collaboration has made some progress in the management of severe acute pancreatitis (SAP). However, infected pancreatic necrosis (IPN) is still a recognized challenge in the treatment of SAP and is also critical to the treatment efficacy of SAP. This study was to analyze and summarize the clinical efficacy of small incision combined with endoscopic minimally invasive surgery in the treatment of IPN.Methods The clinical data of 9 patients with IPN receiving the treatment of small incision combined with endoscopic minimally invasive surgery in the Department of Hepatobiliary Surgery of Changde First People's Hospital from June 2019 to June 2021 were retrospectively analyzed.Results Of the 9 patients, 7 were males and 2 were females, with an average age of (46.7±11.6) years; 5 cases were hyperlipidemic pancreatitis, 2 cases were biliary pancreatitis and 2 cases were alcoholic pancreatitis; the positive rate of the bacterial and fungal culture of pus was 77.8% (7/9). Small incision combined with endoscopic minimally invasive surgery was completed in all patients, which was performed via the left retroperitoneal approach in 4 cases, via the small omental sac approach in 3 cases, and the combined approach in 2 cases. The time from the onset of pancreatitis to the first operation was (47.2±10.1) d, the length of postoperative hospital stay was (20.4±9.6) d, the total length of hospital stay was (36.1±18.1) d, the operative time was (151.7±55.2) min, the weight of necrotic tissue removed was (240.0±119.6) g, the volume of intraoperative blood loss was (55.4±44.2) mL, and the median number of drainage tubes placed was 4 (3-6). Eight patients were cured by one session of surgery, and one patient underwent percutaneous drainage of peripancreatic abscess and choledochoscopic operation again after the first operation. Postoperative complications occurred in 2 patients, including one case of abdominal hemorrhage and one case of colonic fistula. All 9 patients were uneventfully discharged smoothly, and no death occurred.Conclusion Small incision combined with minimally invasive endoscopic surgery integrates the advantages of multiple minimally invasive techniques, which balances the contradiction between debridement efficiency and surgical trauma. It can efficiently and thoroughly remove the necrotic tissues while ensuring the safety of patients at the same time. So, it is recommended to be promoted.

7 Effect of Huoxueqingjie decoction on intestinal immune barrier function in rats with severe acute pancreatitis and the mechanism

LIANG Chao , WANG Yang , LIU Xinbo , LI Shanbao

2022, 31(9):1182-1193. DOI: 10.7659/j.issn.1005-6947.2022.09.007

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Background and Aims Severe acute pancreatitis (SAP) is always associated with intestinal immune barrier dysfunction. The authors previously found that Huoxueqingjie (HXQJD) decoction can alleviate SAP damage, but whether this action is involved in the intestinal immune barrier function is unclear. Therefore, this study was conducted to investigate the effect of HXQJD decoction on the intestinal immune barrier function in rats with SAP, and the mechanism.Methods The SD rats were randomly divided into sham operation group, SAP model group (SAP group), and SAP model plus HXQJD decoction treatment group (treatment group). The SAP model was established by retrograde biliopancreatic duct infusion of 5% sodium taurocholate (NaT). After the operation, HXQJD decoction was administrated by gavage in the treatment group, and the sham operation group and model group were treated with normal saline in the same fashion. Rats were sacrificed at 6 and 12 h after the operation. The serum pro-inflammatory factor TNF-α, anti-inflammatory factor IL-4, as well as blood amylase and lipase levels were detected by ELISA assay. The pathological changes in the pancreas and small intestine were observed by HE staining. The expressions of M1 macrophage phenotype marker iNOS and M2 macrophage phenotype marker Arg-1 in small intestine tissue were determined by qRT-PCR and Western blot. Rat intestinal macrophages were treated with NaT, HXQJD decoction, or NaT plus HXQJD decoction, respectively, using the untreated rat intestinal macrophages as blank control. The expressions of NF-κB, iNOS, TNF-α, Arg-1, IL-4, TIPE2, and PPAR-γ were examined by qRT-PCR and Western blot, respectively.Results In invivo study, the levels of TNF-α, IL-4, and serum amylase and lipase were increased in different degrees after operation in model group and treatment group compared with sham operation group (partial P<0.05), but the increasing amplitudes of TNF-α, and serum amylase and lipase were lower while increasing amplitude of IL-4 was greater in treatment group than those in model group (all P<0.05); evident pathological injuries were seen in the pancreas and small bowel in both model group and treatment group, but the degrees of injuries were milder in treatment group than those in model group, the injuries were worsened in model group while were alleviated in treatment group with the prolongation of time, and the pathological scores for pancreatic and intestinal tissues were significantly different between model group and treatment group (all P<0.05); the protein and mRNA expression levels of iNOS in the small intestinal tissue were significantly increased in model group while were significantly decreased in treatment group (all P<0.05), and the protein and mRNA expression levels of Arg-1 were significantly increased in late stage in model group while were significantly increased in both early and late stages in treatment group with greater increasing amplitudes than those in model group (all P<0.05). In invitro study, the protein and mRNA expression levels of NF-κB, iNOS, and TNF-α were significantly increased (all P<0.05) while Arg-1, IL-4, TIPE2, and PPAR-γ showed no significant changes (all P>0.05) in the rat intestinal macrophages after NaT treatment alone; the protein and mRNA expression levels of Arg-1, IL-4, TIPE2, and PPAR-γ were significantly increased (all P<0.05) while NF-κB, iNOS, and TNF-α showed no significant changes (all P<0.05) in the rat intestinal macrophages after HXQJD decoction treatment alone; the protein and mRNA expression levels of NF-κB, iNOS, and TNF-α were significantly decreased while Arg-1, IL-4, TIPE2, and PPAR-γ were significantly increased in rat intestinal macrophages after NaT plus HXQJD decoction treatment compared with those after NaT treatment alone (all P<0.05).Conclusion HXQJD decoction offers a protective effect on the intestinal immune barrier function in SAP rats, and its action mechanism may be associated with it regulating the transformation of intestinal macrophages from M1 type to M2 type, promoting the expression of anti-inflammatory factors and inhibiting the release of pro-inflammatory factors, thereby alleviating the systemic inflammatory response.

8 Bioinformatics analysis of prognostic significance and mechanism of annexin A5 in pancreatic cancer

ZHONG Chengcheng , LI Mingxu , ZHANG Gongming , HU Wei , WANG Zhong

2022, 31(9):1194-1202. DOI: 10.7659/j.issn.1005-6947.2022.09.008

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Background and Aims Pancreatic cancer is an invasive disease with a late diagnosis and poor prognosis. The studies on the molecular mechanism of pancreatic cancer are of great significance in improving the prognosis of patients with pancreatic cancer. Annexin A5 (ANXA5) is closely related to the occurrence and development of human tumors, but the association of ANXA5 with the prognosis and its mechanism are not very clear. Therefore, this study was conducted to investigate the relationship between the expression of ANXA5 and the prognosis of pancreatic cancer and its action mechanism by bioinformatics analysis combined experimental verification.Methods The transcriptome and clinical data of pancreatic cancer were downloaded from TCGA and GEO databases (GSE15471, GSE16515, GSE21501). The expression of ANXA5 gene in pancreatic cancer tissue and adjacent normal tissue in GEO database was analyzed by R packet, and the expression of ANXA5 gene in pancreatic cancer tissue in TCGA database and normal tissue in GTEx database was analyzed by GEPIA online website. The effect of ANXA5 expression on the overall survival time of patients with pancreatic cancer was analyzed by Kaplan-Meier method, and the risk factors of pancreatic cancer were determined by univariate and multivariate Cox analysis. The possible signal pathway of ANXA5 in pancreatic cancer and its correlation were analyzed using GSEA. Finally, immunohistochemical method was used to detect the expression of ANXA5 in 49 cases of pancreatic cancer and adjacent tissues, and its relationship with prognosis and clinicopathologic features of pancreatic cancer was analyzed.Results The results of database analysis showed that ANXA5 expressions were significantly increased in pancreatic cancer tissues in GSE15471 and GSE16515 data sets as well as in TCGA database (all P<0.05); the overall survival time of patients with high expression of ANXA5 was significantly shorter than that of patients with its low expression in either GSE21501 data set or TCGA database (both P<0.05); the expression of ANXA5 was an independent risk factor for the prognosis of pancreatic cancer patients in TCGA (HR=1.819, 95% CI=1.058-3.126, P=0.03); ANXA5 gene was highly correlated with both TGF-β pathway and epithelial-mesenchymal transition (EMT) in pancreatic cancer. The results of analysis of the pancreatic cancer tissue samples showed that the expression of ANXA5 in pancreatic cancer was significantly higher than that in adjacent tissue (P<0.001), and the high expression of this gene predicted a poor prognosis (P=0.008 2); the expression of ANXA5 was an independent risk factor for the prognosis of pancreatic cancer patients in TCGA (HR=3.06, 95% CI=1.046-8.952, P=0.041); the expression of ANXA5 was significantly associated with clinical stage (P=0.000 94) and lymph node metastasis (P<0.001).Conclusion The expression of ANXA5 is increased in pancreatic cancer, and its high expression is a risk factor for the prognosis of patients with pancreatic cancer. The mechanism may be associated with its promoting the development of pancreatic cancer through TGF-β pathway and EMT process.

9 Machine learning-based feature gene screening of pancreatic cancer

WEI Wei , OU Zhenglin , DOU Xiaolin , ZHANG Shuai , TANG Ling

2022, 31(9):1203-1209. DOI: 10.7659/j.issn.1005-6947.2022.09.009

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Background and Aims Pancreatic cancer is a difficult-to-treat disease and over 90% of the patients will die within one year of diagnosis. The presence of differentially expressed genes (DEGs) between diseased and normal pancreatic cancer tissues may closely associated with the development and progression of pancreatic cancer. This study was conducted to screen the DEGs in pancreatic cancer using a machine learning approach, so as to provide a basis for studying the pathogenetic mechanism of this disease.Methods Pancreatic cancer gene expression profiles were screened from the public gene GEO database, differential calculations and normalizations were performed using the linear regression model package Limma for different groups of microarrays. The DEGs were obtained using the R language, and the selected DEGs were further screened by correlation-based feature selection method. Based on the hub DEGs obtained, AdaBoost and Bagging algorithms were used to construct pancreatic cancer prediction models respectively. The GO function analysis and KEGG enrichment analysis of the hub DEGs were performed through the DAVID website, and protein-protein interaction (PPI) network of the hub DEGs was analyzed using STRING database and Cytscape software. Finally, survival analysis was performed on the relevant hub DEGs through the GEPIA website.Results Through feature screening, 18 key DEGs were obtained. A prediction model was built by using AdaBoost algorithm based on the feature subset containing the 18 DEGs, and the prediction accuracy reached 92.3%. The GO and KEGG analysis of the DEGs revealed an indirect role for CDK1, CCNA2 and CCNB1 in the formation and development of pancreatic cancer. Survival analysis showed that the expressions of CDK1 (P=0.000 8), CCNB1 (P=0.012), CSK2 (P=0.023) and CKS1B (P=0.001 3) were correlated with the overall survival (OS) of patients, and higher expressions of them were associated with shorter OS of patients.Conclusion Machine learning methods can be efficiently applied for hub genes screening in pancreatic cancer, and have certain significance for the diagnosis and treatment of pancreatic cancer and related drug development.

10 Meta-analysis of the association of lncRNA NEAT1 with prognosis and clinicopathologic features of digestive system malignant tumors

LE Qi , LU Kun , ZHU Junya , JIANG Lei , YAO Nan , WANG Jun

2022, 31(9):1210-1219. DOI: 10.7659/j.issn.1005-6947.2022.09.010

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Background and Aims Long non-coding RNA nuclear-enriched transcript 1 (lncRNA NEAT1) is dysregulated in a variety of solid tumors and closely related to poor prognosis, but its relationship with the prognosis of patients with digestive system malignancies is still not clear. Therefore, this study was conducted to investigate the effect of lncRNA NEAT1 on the prognosis of patients with malignant tumors of the digestive system and its relationship with clinicopathologic features by systematic review and Meta-analysis.Methods The published cohort studies on the relationship between lncRNA NEAT1 expression and the prognosis or clinicopathologic characteristics of patients with digestive system malignancies were collected by searching the PubMed, Web of Science, Cochrane Library, China Knowledge Infrastructure and Wanfang databases. The search period was from the inception of the databases to 18th October 2021. Literature screening was performed by two investigators according to the inclusion and exclusion criteria, and the relevant data were extracted. Stata 12.0 software was used for statistical analysis.Results A total of 20 studies involving 2 031 patients with malignant tumors of the digestive system were finally included. The NOS scores of the included studies ranged from 6 to 9, of which 16 studies reported overall survival (OS), 5 studies reported disease-free survival (DFS), and 19 studies reported clinicopathologic features. Meta-analysis revealed that the OS (HR=1.66, 95% CI=1.41-1.97, P<0.001) and DFS (HR=2.0, 95% CI=1.51-2.65, P<0.001) of patients with digestive system malignancies and with higher NEAT1 expression were lower than those of patients with lower or no NEAT1 expression. The results of subgroup analysis according to survival analysis methods, NEAT1 expression cut-off values, number of samples, and follow-up time showed that the OS of patients with high NEAT1 expression were all significantly decreased (all P<0.05). In addition, the results of clinicopathologic characteristics analysis revealed that patients with higher levels of NEAT1 had a high risk of large tumor diameter (OR=2.20, 95% CI=1.73-2.79, P<0.001), advanced clinical stage (OR=3.10, 95% CI=1.95-4.92, P<0.001), lymph node metastasis (OR=1.94, 95% CI=1.30-2.90, P=0.001) and distant metastasis (OR=2.58, 95% CI=1.88-3.54, P<0.001), but it was irrelevant to the age, sex, tumor differentiation and vascular invasion of patients (all P>0.05).Conclusion The high expression of lncRNA RNA NEAT1 is an adverse prognostic factor for malignant tumors of the digestive system, and is also closely associated with unfavorable clinicopathologic features, which may be used as an important reference index for monitoring the condition and prognosis of malignant tumors of the digestive system.

11 Application value of indocyanine green combined with near-infrared imaging technique in laparoscopic colorectal cancer surgery

DENG Ming , HU Gui , LI Xiaorong , LIN Changwei , GUO Yihang , ZHANG Yi

2022, 31(9):1220-1228. DOI: 10.7659/j.issn.1005-6947.2022.09.011

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Background and Aims Lymph node dissection and digestive tract reconstruction are important issues to be solved in colorectal cancer surgery, and indocyanine green (ICG) imaging technology has been widely used in clinical practice with good results in recent years. The purpose of this study was to investigate the application value of ICG and near-infrared fluorescent imaging (ICG-NIR) in laparoscopic colorectal cancer surgery.Methods The clinical data of 234 patients undergoing laparoscopic radical resection of colorectal cancer from July 2019 to December 2020 in the Department of Gastrointestinal Surgery of the Third Xiangya Hospital, Central South University were analyzed retrospectively. Of the patients, ICG-NIR imaging technology was used in 37 cases during operation (ICG group), and 137 cases underwent the conventional laparoscopic procedure without using ICG-NIR imaging technology (non-ICG group). The general data, surgical variables, and intraoperative and postoperative complications were compared between the two groups of patients.Results There was no significant difference in baseline data between the two groups (all P>0.05). There were no significant differences between ICG group versus the non-ICG group in terms of the average intraoperative blood loss (87 mL vs. 98 mL), average operative time (195 min vs. 220 min), and surgical procedures between the two groups (all P>0.05). In the ICG group, 2 cases underwent re-anastomosis after changing the surgical margins during operation because the ICG fluorescent imaging showed poor blood flow in the anastomosis, while no surgical plan change was made in the non-ICG group. The unplanned operation rate between the two groups had a statistical difference (P=0.024). There were no significant differences between the ICG group versus the non-ICG group in the median time to the first postoperative gas passage (3 d vs. 3 d), the median length of hospitalization (10 d vs. 10 d), the incidence rate of anastomotic leakage (2.7% vs. 5.5%), the overall incidence of complications (5.4% vs. 8.1%) and the mean comprehensive complication index (20.03 vs. 18.16) (all P>0.05). The mean number of lymph nodes detected in the ICG group was higher than that of the non-ICG group (17.37 vs. 14.29, P=0.002), but there were no statistically significant differences in the mean number of positive lymph nodes (1.40 vs. 1.45) and proportion of cases with lymph node metastasis (32.4% vs. 39.5%) between the two groups (both P>0.05).Conclusion The application of the ICG fluorescence technique in laparoscopic radical resection for colorectal cancer is safe and feasible. It can guide lymph node dissection to improve operation quality and assist in real-time evaluation of intestinal perfusion. However, it shows no advantages in reducing the incidence of anastomotic leakage and overall complications.

12 Treatment of rectal stenosis by magnetic compression technique: a case report and literature review

ZHANG Miaomiao , GAO Yi , SHA Huanchen , REN Mudan , HE Shuixiang , XU Shuqin , XU Kedong , QU Kai , XIANG Junxi , SONG Xiaogang , QIN Yuanfa , JIAN Zhiyuan , LU Yi , YAN Xiaopeng

2022, 31(9):1229-1236. DOI: 10.7659/j.issn.1005-6947.2022.09.012

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Background and Aims Anastomotic stenosis after rectal cancer surgery is a frequently encountered problem in clinical practice. Endoscopic balloon dilatation is a common minimally invasive treatment. However, endoscopic treatment is difficult to perform for the anastomotic site with severe stricture or even occlusion. This paper is to introduce the diagnosis and treatment experience of a case of severe rectal stenosis and a longer stenotic segment after rectal cancer surgery which was cured successfully by a self-designed and developed magnetic ring under endoscopic-assistance according to the principle of magnetic compression technique (MCT), so as to provide a new perspective and approach for the minimally invasive treatment of rectal stenosis.Methods The clinical data of a patient with rectal stenosis after rectal cancer surgery treated in the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Xi'an Jiaotong University were retrospectively analyzed. The patient was a 66-year-old male who was scheduled to undergo ileostomy reduction 6 months after radical resection for rectal cancer. In the patient, lower rectal stenosis was observed during colonography, and the implementation of endoscopic balloon dilatation failed in the local hospital. Then, the patient came to our hospital for MCT stenosis recanalization. At the same time, the literature about MCT in the treatment of rectal stenosis or atresia was extracted and analyzed.Results NdFeB magnetic rings with titanium nitride coating surface were used in the patient. During the operation, the magnetic rings were inserted into both ends of the stenosis segment through the ileostomy and anus respectively with the aid of an endoscope. The magnet rings were difficult to attract each other effectively because of the long stenotic segment. Then the operative approach was changed. The zebra guide wire was inserted through the ileostomy under endoscopic guidance and the guide wire passed through the stenotic segment of the rectum and was led out of the body through the anus. The assembled magnetic rings were inserted into both ends of the rectal stenosis through the ileostomy and anus along the zebra guide wire. The magnets were attracted to each other in the right position. As time went on, the distance between the magnets increasingly shortened, and the magnetic rings were discharged spontaneously through the anus 6 d after the operation. Immediate colonoscopy was performed which showed the recanalization of rectal anastomosis, and catheter support was given. The patient returned to the local hospital and successfully underwent ileostomy reduction as planned. Follow-up was conducted for 5 months until manuscript preparation, and the patient exhibited normal defecation. The literature search found that there were 4 cases of rectal stenosis/atresia treated by MCT at home and abroad. Although the operative approach and magnetic rings used in these cases were different, satisfactory treatment results were finally achieved in all of them.Conclusion Patients with rectal stenosis have different causes, and there are great differences in the degree and length of stenosis. When using MCT as a treatment method, individual differences in the condition of patients should be fully considered, and the selection of the most appropriate operative approach and magnetic rings is the premise of obtaining favorable treatment results. As a new type of anastomosis, MCT combined with endoscopy in the treatment of rectal stenosis has the advantages of simple operation, less trauma, and demonstrable efficacy.

13 Giant Brunner's gland hamartoma with associated chronic anemia: a case report and literature review

WU Dongdong , DONG Hao , MA Fuping

2022, 31(9):1237-1242. DOI: 10.7659/j.issn.1005-6947.2022.09.013

[Abstract](638) [HTML](693) [PDF 736.70 K](1149)

Abstract:
Background and Aims Brunner's gland hamartoma (BGH) is a rare type of duodenal benign tumor. It is difficult to diagnose before operation and often easily to be missed or misdiagnosed because of atypical clinical manifestations and lack of specificity. The diagnosis mainly depends on postoperative pathology. The cases of giant BGH are rare. This paper reports the diagnosis and treatment of a case of giant BGH with associated chronic anemia, and reviews the characteristics of this disease in combination with the previous literature, so as to provide experience for clinical management of this condition.Methods The clinical data of a patient with BGH admitted to the Department of Hepatobiliary Surgery of Xianyang Central Hospital Affiliated to Xi'an Jiaotong University were analyzed retrospectively in combination with a review of the previous literature.Results The patient was a 49-year-old female, and was admitted to the Department of Hepatobiliary Surgery of Xianyang Central Hospital Affiliated to Xi'an Jiaotong University because of abdominal pain accompanied by nausea and vomiting. The patient had a history of chronic anemia, regular menstruation, and occasional black stool. On admission, the B-ultrasound examination of the upper abdomen showed the mass of the duodenum overlapped by the head of the pancreas; CT examination of the upper abdomen showed diffuse thickening of the intestinal wall in the descending and horizontal parts of the duodenum, with unclear structure; MRI+MRCP examination of the upper abdomen showed that the descending and horizontal parts of the duodenum and the adjacent jejunum were indistinct, the intestinal tube was obviously distended and twisted, the intestinal wall was indistinct, with obvious intestinal wall edema and presence of concentric circles change. Duodenal space occupying was considered in gastroscopy, and biopsy under endoscopy suggested that it was consistent with the ectopic gastric mucosa. The upper gastrointestinal angiography showed a nearly round filling defect at the junction of the descending and horizontal segments of the duodenum, considered to be a benign occupying lesion. Finally, the obstruction caused by the duodenal space-occupying lesion was considered, and pancreaticoduodenectomy was performed after exploratory laparotomy. The final diagnosis was BGH and immunohistochemical staining for MUC5AC positive after the resected specimen was sent to pathological examination. The patient recovered uneventfully after surgery and was discharged from the hospital. After the operation, the blood routine was monitored, and the red blood cells and hemoglobin gradually returned to normal. The patients were followed up for 12 months. The patients were generally in good condition without complaints of discomfort. All indexes were normal in the reexamination, and the follow-up was continued.Conclusion Giant BGH with associated chronic anemia is rare in clinical practice. Preoperative imaging examination is often difficult to provide valuable information. Biopsy under gastroscope is helpful for diagnosis, but the positive rate is low. The final diagnosis depends on histopathological examination of the surgical specimens. Surgical resection is an effective means to treat the disease when the lesion is large.

14 Research progress on the application value of pancreatic stellate cells in the treatment of pancreatic cancer

LI Weibo , CHANG Jian , XIONG Xingcheng , TANG Zhigang

2022, 31(9):1243-1248. DOI: 10.7659/j.issn.1005-6947.2022.09.014

[Abstract](707) [HTML](801) [PDF 643.63 K](1205)

Abstract:
Pancreatic cancer is characterized by high malignancy, rapid progression, early metastasis, chemotherapy resistance, and no specific targeted drugs due to its complex tumor microenvironment (TME). Pancreatic stellate cells (PSCs) are inert lipid storage cells of the pancreas and an important part of the TME. Targeting tumor-stromal crosstalk in the TME has become a promising therapeutic strategy against pancreatic cancer progression and metastasis. Therefore, the authors address the interaction of PSCs in the pancreatic cancer TME and the potential treatment application of targeted activation of PSCs, to provide new targets and new ideas for the treatment of pancreatic cancer.

15 Research progress on the effect of stellate cells in pancreatic ductal adenocarcinoma microenvironment on tumor angiogenesis

LIU Jiao , ZHAO Jianguo

2022, 31(9):1249-1254. DOI: 10.7659/j.issn.1005-6947.2022.09.015

[Abstract](655) [HTML](541) [PDF 609.56 K](1073)

Abstract:
Pancreatic ductal adenocarcinoma (PDAC) is the most malignant digestive tumor and is characterized by late detection, early metastasis, and poor prognosis, with a 5-year survival rate of less than 7%. Although severe interstitial fibrosis and lack of blood supply are important features of PDAC tissue, the tumor cells are often accompanied by intense neovascularization. Many cytokines play important roles in promoting tumor angiogenesis directly or indirectly through the bridge of the pancreatic stellate cells (PSCs), but thein specific action mechanism is not entirely clear. Meanwhile, experimental results also showed that the expression of vascular endothelial growth factor (VEGF) was positively correlated with the secretion of galectin-1 and hepatocyte growth factor (HGF) from activated PSCs. Tumor angiogenesis is one of the characteristics of tumors, and angiogenesis is essential for the continuous growth, invasion, and metastasis of PDAC. However, there are relatively few studies on PDAC angiogenesis. Here, the authors address the effects of PSCs in the PDAC microenvironment on tumor angiogenesis, and the potential cancer treatment strategies targeting PSCs to block their function are also discussed.

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Volume 31,Issue 9,2022 Table of Contents

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