Volume 33,Issue 3,2024 Table of Contents

1 Current status of diagnosis and treatment of pancreatic neuroendocrine neoplasms

HE Da , SONG Bin

2024, 33(3):311-320. DOI: 10.7659/j.issn.1005-6947.2024.03.001

[Abstract](190) [HTML](375) [PDF 818.45 K](834)

Abstract:
Neuroendocrine neoplasms (NENs) are rare and highly heterogeneous tumors originating from peptidergic neurons and neuroendocrine cells. They can occur in various sites such as bronchopulmonary and gastroenteropancreatic systems. Pancreatic neuroendocrine neoplasms (pNENs) are the most common in our country, with a significant increase in incidence in recent decades. Here, the authors primarily discusse the latest research status on the classification, diagnosis, and treatment of pNENs, aiming to provide guidance and reference for clinical diagnosis and treatment.

2 Minimal access retroperitoneal pancreatic necrosectomy: operative techniques and perioperative management

ZHU Shuai , WEI Wei , HUANG Gengwen

2024, 33(3):321-329. DOI: 10.7659/j.issn.1005-6947.2024.03.002

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Minimally access retroperitoneal pancreatic necrosectomy (MARPN) is a minimally invasive surgical approach for the treatment of infected pancreatic necrosis (IPN), in which necrotic tissue behind the peritoneum and around the pancreas is cleared using visualized equipment such as nephroscope or flexible endoscope, with the sinus tract as the surgical pathway. However, its popularity still needs to be improved, and further research and discussion are needed on its indications, specific technical details, and postoperative management. In some large-scale pancreatic surgery centers at home and abroad, including the authors' center, MARPN has become the main means of treating IPN, and from the published data, it has shown good therapeutic effects. After years of exploration and practice, the authors' center has accumulated a large number of cases and experiences in MARPN surgery and standardized the steps, procedures, and technical details of the surgery. Here, the authors introduce the operative technique and perioperative management of MARPN, hoping to promote the wider, safer, and more effective implementation of this technique.

3 Evaluation of the application value of preoperative biliary drainage in patients with different degrees of obstructive jaundice undergoing pancreaticoduodenectomy

MA Hongyun , MO Daihai , HE Da , SONG Bin

2024, 33(3):330-340. DOI: 10.7659/j.issn.1005-6947.2024.03.003

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Background and Aims Obstructive jaundice is a common clinical feature of malignant tumors of the head of the pancreas and periampullary region, which can lead to various pathophysiological changes in the body, thereby increasing the risk of complications after pancreaticoduodenectomy (PD). However, there have been significant discrepancies in previous studies regarding the benefits of preoperative biliary drainage (PBD) in such patients and the indications for PBD. Therefore, this study was conducted to further analyze the necessity and indications for PBD in patients with different degrees of jaundice.Methods The clinical data of 358 patients with obstructive jaundice who underwent PD in the First Affiliated Hospital of Naval Medical University from 2016 to 2018 were retrospectively analyzed (including patients undergoing PBD and those undergoing direct surgery). Based on preoperative serum total bilirubin (TBIL) level (TBIL level before drainage for patients undergoing PBD), the patients were divided into mild jaundice group (TBIL <250 μmol/L) and severe jaundice group (TBIL ≥250 μmol/L). The main clinical variables between patients undergoing PBD and those undergoing direct surgery were compared in both groups separately.Results There were 183 cases in the mild jaundice group, including 34 cases undergoing PBD and 149 cases undergoing direct surgery, and 175 cases in the severe jaundice group, including 75 cases undergoing PBD and 100 cases undergoing direct surgery. In both the mild and severe jaundice groups, there were some differences in preoperative baseline data, intraoperative indicators, and postoperative pathology between patients who underwent PBD and those who underwent direct surgery (some P<0.05). Regarding postoperative outcomes, there were no statistically significant differences in the incidence rates of total complications, severe complications, specific complications, and perioperative death, as well as transfusion rate, and length of hospital stay between patients who underwent PBD and those who underwent direct surgery in the mild jaundice group (all P>0.05). However, in the severe jaundice group, patients who underwent PBD had significantly lower incidence of overall complication, incidence of postoperative bleeding, transfusion rate, and incidence of gastric emptying disorder compared to those who underwent direct surgery (all P<0.05). Multivariate regression analysis showed that PBD was an independent influencing factor for overall postoperative complications (OR=0.444, 95% CI=0.237-0.832, P=0.011) and postoperative bleeding (OR=0.293, 95% CI=0.088-0.978, P=0.046) in patients with severe obstructive jaundice after PD.Conclusion For patients with mild jaundice, the benefit of preoperative PBD before PD is limited, and routine PBD is not recommended. For patients with severe jaundice, PBD can effectively improve postoperative outcomes of PD, and it is recommended to perform PBD when TBIL is ≥250 μmol/L.

4 Clinical efficacy of douching-draining separate drainage tube in the prevention of complications after pancreatic surgery

TANG Wenqiang , WANG Jian , ZHU Zhongfei , HU Xiangui , SONG Bin

2024, 33(3):341-348. DOI: 10.7659/j.issn.1005-6947.2024.03.004

[Abstract](227) [HTML](225) [PDF 851.59 K](748)

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Background and Aims Postoperative complications are important factors affecting the prognosis of patients undergoing pancreatic surgery. An abdominal drainage tube placement is a routine procedure to reduce postoperative complications. Currently, there are various types of drainage tubes with significant differences in efficacy. This study was to introduce a method of using a self-made douching-draining separate drainage tube and explore its clinical application effects.Methods The clinical data of 213 patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) performed by the author's team from the Department of Hepatopancreatobiliary and Splenic Surgery, the First Affiliated Hospital of Naval Medical University from January 1, 2021 to July 1, 2023 were retrospectively analyzed. All patients were treated with the self-made douching-draining separate drainage tube. The proportion of textbook outcome (TO) achieved in both procedures, the incidence rates of postoperative specific complications and severe complications (Clavien-Dindo complications classification grade≥Ⅲ), postoperative hospital stay, 30-d readmission rate, and 30-d and 90-d mortality rates were statistically analyzed and compared with relevant literature.Results Among the 213 patients, 143 underwent PD, and 70 underwent DP, with TO rates of 69.2% (99/143) and 81.4% (57/70), respectively. The 30-d and 90-d mortality rates for PD patients were 0.7% (1/143), while for DP patients, both were 0 (0/70). The incidence of pancreatic fistula (grade B/C) in PD and DP patients was 9.8% (14/143) and 8.6% (6/70), respectively, bile leakage (grade B/C) occurred in 4.2% (6/143) and 0 (0/70), postoperative hemorrhage (grade B/C) occurred in 6.3% (9/143) and 0 (0/70), gastric emptying disorder (grade B/C) occurred in 7.7% (11/143) and 2.9% (2/70), and the incidence of severe complications was 18.2% (26/143) and 7.1% (5/70), respectively. The postoperative hospital stays were 11 (9-14) d and 7 (6-10) d for PD and DP patients, respectively, and the 30-d readmission rates were 9.8% (14/143) and 7.1% (5/70), respectively. Compared with relevant literature, the TO rate of patients in this group was higher, with decreased 30-d and 90-d mortality rates, decreased incidence of postoperative pancreatic fistula, bile leakage, postoperative hemorrhage, gastric emptying disorder, severe complications, and 30-d readmission rates.Conclusion Using a self-made douching-draining separate drainage tube after pancreatic surgery can relatively increase the TO rate, effectively reduce perioperative mortality and the incidence of related complications and severe complications, as well as the 30-d readmission rate, thereby improving the perioperative safety of patients. It has a positive significance for postoperative recovery and patient prognosis.

5 Clinical analysis of 50 cases of robot-assisted pancreatic surgery during learning curve period in a single center

HUANG Junfu , XIN Wanpeng , YI Siqing , TU Shuju , XIONG Yuanpeng , JIANG Hai , WAN Zhen , XIAO Weidong

2024, 33(3):349-356. DOI: 10.7659/j.issn.1005-6947.2024.03.005

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Background and Aims Since the approval of the da Vinci robotic surgical system for clinical use in 2000, robot-assisted surgery has been widely adopted across various disciplines. Due to the complexity of pancreatic and periampullary anatomy, the application of robotic surgery systems in pancreatic surgery started later compared to other specialties. Although a few high-volume pancreatic surgery centers have accumulated experience with thousands of cases of robot-assisted pancreatic surgery (RPS), most units are still in the learning curve stage. This study was conducted to summarize the clinical efficacy and experience of RPS performed during the learning curve period in the authors' center, so as to provide reference information for clinical practice.Methods The clinical data of 50 patients undergoing RPS in the First Affiliated Hospital of Nanchang University from January 2020 to September 2022 were retrospectively analyzed. Among them, there were 23 cases of pancreaticoduodenectomy, 9 cases of tumor enucleation, 8 cases of distal pancreatectomy with splenectomy, 6 cases of central pancreatectomy, 2 cases of duodenum-preserving pancreatic head resection, and 2 cases of spleen-preserving distal pancreatectomy. All surgeries were performed by the same team.Results The mean operative time was (275±115) min, with (330±78) min for pancreaticoduodenectomy and (236±59) min for distal pancreatectomy with splenectomy. The average intraoperative blood loss was (315±259) mL. The incidence rates of overall complications and clinically relevant pancreatic fistula were 30.0% and 10.0%, respectively. The rate of Clavien-Dindo grade Ⅲ or above complications was 6.0% (3/50), with no deaths within postoperative 30 d, a conversion rate of 4%, and a reoperation rate of 2%. The mean length of postoperative hospital stay was (13.2±7.7) d. Among the malignant tumor patients (27 cases), the average number of lymph nodes retrieved was 14 (4-34). The average follow-up period was (23.4±9.3) months, with two cases of pancreatic cancer recurrence at 12 and 14 months after operation, while the remaining patients showed no tumor recurrence.Conclusion By rigorously adhering to surgical indications and drawing extensively from mature experiences, conducting RPS progressively advancing from simpler to more challenging cases during the learning curve period, is safe and feasible.

6 Diagnosis and treatment of pancreatic serous cystic neoplasms: a report of 104 cases

ZHU Zhongfei , MAO Kuanzheng , ZHANG Jiachen , SONG Bin

2024, 33(3):357-365. DOI: 10.7659/j.issn.1005-6947.2024.03.006

[Abstract](219) [HTML](317) [PDF 893.98 K](718)

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Background and Aims Pancreatic serous cystic neoplasms (SCN) are benign diseases with an extremely low rate of malignant transformation. However, preoperative differentiation diagnosis of them is difficult, often requiring surgical resection to exclude malignant lesions. Improving the accuracy of preoperative diagnosis of pancreatic SCN can reduce unnecessary surgeries, thus mitigating surgical risks and complications. Therefore, this study was conducted to investigate the factors influencing the accurate diagnosis of pancreatic SCN through data analysis of pancreatic SCN patients who had undergone surgical resection.Methods The clinical data of 231 patients who underwent surgical resection for pancreatic cystic neoplasms and were pathologically confirmed between June 2018 and December 2020 in the Department of Hepatobiliary and Pancreatic Surgery of the First Affiliated Hospital of Naval Medical University were retrospectively collected. Among them, 104 cases (45.02%) were SCN, and 127 cases (54.98%) were non-SCN. Surgical procedures and postoperative complications of SCN and non-SCN patients were compared. The value of preoperative imaging examinations in SCN patients and factors interfering with preoperative correct diagnosis were analyzed.Results Among the 104 SCN patients, 62 cases (59.62%) were incidentally found during health maintenance examination, and 77 cases (74.04%) had tumors located in the body or tail of the pancreas. After operation, biochemical leak occurred in 55 cases, grade B pancreatic fistula occurred in 3 cases, grade A/B gastric emptying disorder occurred in 8 cases, grade C gastric emptying disorder occurred in 3 cases, and postoperative bleeding occurred in 1 case. Among the 127 non-SCN patients, 83 cases (65.35%) were incidentally found during health maintenance examination, and 103 cases (81.10%) had tumors located in the body or tail of the pancreas. After operation, biochemical leak occurred in 51 cases, grade B pancreatic fistula occurred in 1 case, grade A/B gastric emptying disorder occurred in 11 cases, grade C gastric emptying disorder occurred in 3 cases, and postoperative bleeding occurred in 1 case. There was no statistically significant difference in surgical methods and the incidence rates of severe postoperative complications (pancreatic fistula, gastric emptying disorder, and bleeding) between SCN and non-SCN patients (all P>0.05). The preoperative correct diagnosis rate of SCN was 32.69% (34 cases) in the 104 SCN patients, with correct diagnoses made by enhanced abdominal CT in 19 cases and enhanced pancreatic MRI in 15 cases. Among them, 12 cases showed cystic wall enhancement, 19 cases had internal septations, 5 cases had intracystic calcification, 6 cases had solid components, and 3 cases had main pancreatic duct dilation. Univariate analysis indicated that the type of auxiliary examination (P=0.012), cyst wall enhancement (P=0.065), presence of internal septations (P=0.002), presence of intracystic calcifications (P=0.077), presence of intracystic solid components (P=0.019), and main pancreatic duct dilation (P=0.094) were related to the correct diagnosis of SCNs. Multivariate analysis results showed that MRI examination (OR=3.619, 95% CI=1.274-10.729, P=0.016) and internal septations (OR=3.610, 95% CI=1.289-10.107, P=0.015) were independent factors affecting the correct diagnosis of SCN, and intracystic solid components (OR=0.334, 95% CI=0.107-1.039, P=0.058) and main pancreatic duct dilation (OR=0.025, 95% CI=0.184-0.042, P=0.025) were independent factors for exclusion diagnosis.Conclusion The preoperative correct diagnosis rate of pancreatic SCN is relatively low. Although surgical resection has a low incidence of severe postoperative complications, the benefits are limited. Combined with enhanced MRI examination of pancreas before operation, establishment of radiological deep learning model, and where feasible, the utilization of endoscopic ultrasound examinations can improve the ability to identify the imaging characteristics of SCN, thereby enhancing the accuracy of preoperative diagnosis and improving the rationality of surgical decision-making for pancreatic SCN.

7 Construction and validation of a risk prediction model for clinically relevant pancreatic fistula after pancreaticoduodenectomy

ZHANG Danyang , LEI Peng , ZHANG Yubo , YANG Gang , ZHANG Wei

2024, 33(3):366-375. DOI: 10.7659/j.issn.1005-6947.2024.03.007

[Abstract](317) [HTML](186) [PDF 1.14 M](547)

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Background and Aims With the advancement of surgical techniques and clinicians' continuous refinement of surgical approaches, the surgical mortality of pancreaticoduodenectomy (PD) has significantly decreased. However, the incidence of postoperative complications remains high, with postoperative pancreatic fistula (POPF) being the most common and severe. Therefore, this study was conducted to investigate the risk factors for clinically relevant POPF (CR-POPF) after PD and develop a risk prediction model.Methods The clinical data of 365 patients who underwent PD in the Department of Hepatobiliary Surgery of General Hospital of Ningxia Medical University from January 2015 to July 2021 were retrospectively collected. Patients were randomly divided into modeling and validation groups at a ratio of 7∶3 based on a random number generator. Univariate and multivariate Logistic regression analyses were conducted on the modeling group to determine independent risk factors for CR-POPF. A clinical prediction model was constructed and visualized using a nomogram. The discriminative ability was evaluated using the ROC curve, and Bootstrap drew the calibration curve and repeated the self-sampling method for internal validation. The validation group was incorporated into the model to verify the predictive performance of the model by drawing the ROC curve and calibration curve.Results Univariate analysis showed that sex, BMI, history of abdominal surgery, main pancreatic duct diameter, pancreatic texture, neutrophil count, monocyte count, lymphocyte count, the ratio of monocytes to lymphocytes, and postoperative lactate were significantly associated with CR-POPF (all P<0.05). Multivariate Logistic regression analysis revealed that male sex (OR=2.896, 95% CI=1.368-6.390), high postoperative lactate (OR=3.593, 95% CI=2.211-6.172), main pancreatic duct diameter ≤3 mm (OR=0.243, 95% CI=0.102-0.552), and soft pancreatic texture (OR=0.146, 95% CI=0.061-0.331) were independent risk factors for CR-POPF (all P<0.05). A mathematical model was established based on regression coefficients, and a nomogram was constructed for visualization. The area under the ROC curve (AUC) of the model was 0.897 (95% CI=0.857-0.936); calibration assessment showed that the trend of the simulated curve was consistent with the actual curve (MAE=0.014). The validation group data were applied to the prediction model, and the ROC curve for predicting the risk of POPF CR-POPF in the validation group showed an AUC of 0.901 (95% CI=0.844-0.959); the calibration curve demonstrated that the trend of the simulated curve in the validation group was consistent with the actual curve (MAE=0.019).Conclusion Male sex, soft pancreatic texture, main pancreatic duct diameter ≤3 mm, and high postoperative lactate are closely associated with the occurrence of POPF after PD. A predictive model for early postoperative CR-POPF based on these four variables demonstrates good performance and can guide clinicians in making treatment plans for patients undergoing PD.

8 Influence of hepatocyte-derived exosomes under high-glucose condition on the migration and invasion abilities of pancreatic cancer cells

YANG Haochang , XU Yongning , LIAO Jiahua , YANG Xinyue , QIN Wen

2024, 33(3):376-385. DOI: 10.7659/j.issn.1005-6947.2024.03.008

[Abstract](293) [HTML](148) [PDF 1.78 M](776)

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Background and Aims In the influence and regulation of the tumor microenvironment, certain non-tumor cells play crucial roles in tumor metastasis through exosomes. Studies have indicated that in pancreatic cancer, a high-glucose microenvironment can promote its invasion and metastasis. The liver, being a vital organ for glucose metabolism, is also a common site for pancreatic cancer metastasis, yet the mechanisms underlying pancreatic cancer liver metastasis remain unclear. Therefore, this study was conducted to investigate the effect of exosomes secreted by liver cells under high-glucose condition on the invasion and migration of pancreatic cancer cells and the possible mechanism.Methods Immortalized liver cells MIHA were cultured in either high-glucose or normal glucose media, and exosomes were extracted from the supernatant. The exosomes from both medium sources were identified using transmission electron microscopy, particle size analysis, and Western blot. Exosomes from both medium sources were labeled with fluorescent dye PKH67 and co-cultured with pancreatic cancer cells PANC-1 labeled with fluorescent dye DAPI, and then the uptake of exosomes by PANC-1 cells was observed using real-time laser scanning confocal microscopy. PANC-1 cells were co-cultured with exosomes derived from high-glucose medium (high-glucose group) or normal glucose medium (normal glucose group), with PANC-1 cells cultured without exosomes serving as a negative control group. Subsequently, wound-healing assay and Transwell assay were performed to assess the migration and invasion abilities of PANC-1 cells in each group, and Western blot was used to detect the expression of epithelial-mesenchymal transition (EMT)-related proteins E-cadherin and N-cadherin in PANC-1 cells.Results Transmission electron microscopy showed the extraction of numerous spherical vesicles with lipid bilayer membrane structures from the supernatant of MIHA cells cultured in both media, with diameters ranging from 40-150 nm. Western blot revealed positive expression of exosome marker proteins CD9 and CD63 in the extracts. Real-time laser scanning confocal microscopy demonstrated the uptake of exosomes from both medium sources by PANC-1 cells. Wound-healing assay and Transwell assay showed that the migration rate, number of migrating cells, and number of invading cells in the high-glucose group were significantly higher than those in the negative control group (all P<0.05). Western blot results showed a significant decrease in E-cadherin protein expression and a significant increase in N-cadherin protein expression in PANC-1 cells in the high-glucose group compared to the negative control group (all P<0.05). There were no statistically significant differences in all parameters between the normal glucose group and the negative control group (all P>0.05).Conclusion Exosomes derived from hepatocytes under high-glucose environment can promote the invasion and migration of pancreatic cancer cells, and the mechanism of action may be associated with regulating the expression of EMT-related proteins in pancreatic cancer cells.

9 Clinical analysis of 147 cases of traumatic pancreatic injury

BAI Yunhu , NAN Bo , ZHANG Ning , DENG Shizhou , WANG Zhenhua , CHEN Xiyu , ZHENG Qianwen , SUN Yuze , WANG Yayun , YANG Yanling

2024, 33(3):386-392. DOI: 10.7659/j.issn.1005-6947.2024.03.009

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Background and Aims Pancreatic trauma, resulting from various factors leading to structural or functional damage to the pancreas, is typically categorized into closed and open injuries. However, pancreatic trauma is not common, and when it occurs, it often accompanies injuries to multiple organs. The unique anatomical location of the pancreas poses challenges in diagnosis and treatment, contributing to the high mortality rate associated with pancreatic trauma, which is often related to delays in diagnosis and treatment. In recent years, with the advancement of industrialization in China, there has been an increasing trend in the incidence of pancreatic trauma, which is also influenced by geographical factors. Therefore, this study was performed to summarize the causes, injury grading, and treatment modalities of pancreatic trauma over a 15-year period at a single center, with the intention of gaining experiential guidance for clinical practice.Methods The clinical data of 147 patients with pancreatic trauma admitted to the First Affiliated Hospital of Air Force Military Medical University from January 2008 to December 2022 were retrospectively analyzed. Pancreatic trauma was graded according to the criteria of the American Association for the Surgery of Trauma (AAST), and the causes, injury grading, corresponding treatment modalities, as well as outcomes were analyzed and summarized.Results There were 15 cases of open injury and 132 cases of closed injury. The most common etiological factor was motor vehicle accidents, accounting for 65 cases (44.22%), followed by physical altercations (blunt or sharp) in 28 cases (19.05%), falls from height in 18 cases (12.24%), other traumas in 10 cases (6.80%), non-traffic-related falls or collisions in 8 cases (5.44%), compression injuries in 4 cases (2.72%), blast injuries in 1 case (0.68%), and 13 cases (8.84%) of injuries with unknown causes. According to the AAST criteria, there were 58 cases of grade I (39.46%), 15 cases of grade Ⅱ (10.21%), 54 cases of grade Ⅲ (36.73%), 9 cases of grade Ⅳ(6.12%), and 11 cases of grade Ⅴ (7.48%). Surgical intervention was performed in 80 cases (54.42%), with a surgery rate of 95.95% for high-grade injuries (grade Ⅲ-Ⅴ). Surgical procedures included distal pancreatectomy in 44 cases, pancreaticoduodenectomy in 11 cases, pancreaticojejunostomy in 5 cases, pancreatic debridement, repair, and drainage in 19 cases, and combined pancreatic head and pancreatic duct repair with distal pancreatectomy in 1 case. ConservatⅣe treatment was performed in 62 cases (42.18%), and endoscopic treatment in 5 cases (3.40%). Among the conservatⅣely treated patients, 24 cases (38.71%) were cured, 37 cases improved, and 1 case died. Among the surgically treated patients, 66 cases (82.50%) were cured, 9 cases improved, 3 cases deteriorated, and 2 cases died. All 5 patients undergoing endoscopic treatment showed improvement.Conclusion The causative factors of pancreatic trauma are commonly associated with traffic collisions, physical altercations, and falls from height. For grade Ⅰ-Ⅱ pancreatic trauma, conservative treatment is mostly feasible, while grade Ⅲ-Ⅴ primarily require surgical intervention, especially distal pancreatectomy or pancreaticoduodenectomy. Prompt surgical intervention is necessary for severe high-grade pancreatic trauma, and even for low-grade injuries, appropriate proactive intervention should be selected based on actual conditions. Pancreatic trauma requires individualized treatment plans based on the pathogenic factors, injury severity, the patient's overall condition, and the medical capabilities of the institution.

10 Clinical features of hypertriglyceridemia acute pancreatitis in pregnancy and predictive factors for severe progression

MEI Lifen , GAN Quan , HU Jing , LI Yunxiang , SHI Chengjian

2024, 33(3):393-399. DOI: 10.7659/j.issn.1005-6947.2024.03.010

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Background and Aims Acute pancreatitis in pregnancy (APIP) is a rare but serious complication during pregnancy, and severe progression of APIP can lead to maternal and fetal death. In recent years, hypertriglyceridemia (HTG) has emerged as a primary cause of APIP. Reports on the clinical characteristics and prognosis factors of APIP caused by HTG are scarce. Therefore, this study was performed to investigate the clinical features of hypertriglyceridemia-induced acute pancreatitis in pregnancy (HTG-APIP) and predictive factors for severe progression.Methods The clinical data from 39 APIP patients treated in the Department of Critical Care Medicine, Hubei Maternal and Child Health Care Hospital and Department of Biliary and Pancreatic Surgery of Wuhan Maternal and Child Health Hospital and Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, from January 2018 to December 2020 was retrospectively analyzed. Patients were categorized into the HTG-APIP group (17 cases) and the non-HTG-APIP group (22 cases) based on triglyceride concentrations. General characteristics, disease severity, and various laboratory parameters were compared between the two groups. Differences in laboratory parameters between mild (MAP) and severe (SAP) cases among the HTG-APIP patients were also analyzed, and risk factors for severe progression of HTG-APIP were assessed using Logistic regression analysis, with the predictive efficacy evaluated using ROC curve.Results Compared with the non-HTG-APIP group, the HTG-APIP group showed significantly higher blood triglyceride level and lower blood calcium level (both P<0.05). In contrast, all other variables showed no significant differences (all P>0.05). Among HTG-APIP patients, there were 8 MAP cases and 9 SAP cases. The SAP group exhibited a significantly higher neutrophil-to-lymphocyte ratio (NLR) compared to the MAP group (P<0.05). Logistic regression analysis revealed NLR as an independent risk factor for severe progression of HTG-APIP (OR=1.120, 95% CI=1.004-1.250, P=0.042), and the area under the ROC curve for predicting severe HTG-APIP was 0.847, with a sensitivity of 75.0%, and a specificity of 88.9%.Conclusions There were no significant differences in the clinical features between HTG-APIP and non-HTG-APIP; elevated NLR can be used to predict the severe progression of HTG-APIP.

11 Analysis of risk factors for gastric venous rupture bleeding caused by pancreatic portal hypertension and construction of nomogram predictive model

LIU Peng , XIANG Xinghua , LI Wenbin , LI Guoguang , ZHU Chaogeng

2024, 33(3):400-407. DOI: 10.7659/j.issn.1005-6947.2024.03.011

[Abstract](129) [HTML](131) [PDF 911.88 K](463)

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Background and Aims The incidence and diagnosis rate of pancreatic-related diseases have been increasing in recent years, leading to a corresponding rise in the incidence and diagnosis rate of pancreatic portal hypertension (PPH) and its complications. PPH can manifest with symptoms such as abdominal pain, splenomegaly, and gastrointestinal bleeding. Gastric venous rupture bleeding is the most severe complication of PPH, which can result in hemorrhagic shock and even death. Currently, there is no recognized standard for predicting the risk of gastric venous rupture bleeding in patients with PPH. Therefore, this study explored the relevant risk factors for gastric variceal rupture/bleeding in PPH patients and established a risk prediction model to provide a reference for preventing and treating this condition in clinical practice.Methods A total of 176 patients with PPH admitted to the First Affiliated Hospital of Hunan University of Chinese Medicine and Hunan Provincial People's Hospital from January 2012 to January 2022 were included in this study. Patients were divided into bleeding group (24 cases) and non-bleeding group (152 cases) based on whether they developed gastric venous rupture bleeding. General information including sex age, etiology, hypertension, and diabetes, laboratory results such as splenomegaly, prothrombin time (PT), thrombin time (TT), fibrinogen (FIB), activated partial thromboplastin time (APTT), and imaging indicators including the inner diameter of the left gastric vein (LGV), the inner diameter of the gastroesophageal vein (GEV), and the GEV inner diameter /LGV inner diameter ratio were collected for both groups. Univariate and multivariate Logistic regression analyses were conducted to identify the influencing factors for PPH complicated with gastric variceal rupture/bleeding, a nomogram risk prediction model was established, and then the predictive efficacy, consistency, and clinical value of the model were evaluated through receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis.Results Univariate analysis showed that diabetes, splenomegaly, PT, FIB, LGV inner diameter, and GEV inner diameter/LGV inner diameter ratio were associated with PPH complicated with gastric variceal rupture/bleeding (all P<0.05). Multivariate Logistic regression analysis revealed that diabetes (OR=0.144, 95% CI=0.031-0.675, P=0.014) and LGV diameter (OR=3.129, 95% CI=1.608-6.090, P=0.001) were independent risk factors for PPH complicated with gastric venous rupture bleeding, while FIB (OR=0.580, 95% CI=0.348-0.966, P=0.037) and GEV/LGV ratio (OR=0.024, 95% CI=0.001-0.696, P=0.030) were independent protective factors. A nomogram model for predicting the risk of gastric venous rupture bleeding in PPH incorporating these factors and clinically significant GEV inner diameter demonstrated an area under the ROC curve of 0.954. The calibration curve and decision curve analysis showed high fitting degree and net benefit values when the risk threshold was between 2% and 85%.Conclusion Diabetes, LGV inner diameter, FIB, and GEV inner diameter/LGV inner diameter ratio are closely related to PPH complicated with gastric venous rupture bleeding. The established nomogram risk prediction model can effectively identify high-risk patients for gastric venous rupture bleeding in PPH and provide a reference for clinical decision-making.

12 Clinical diagnosis and surgical treatment of nonfunctional pancreatic neuroendocrine neoplasms: a review of research progress

GUO Yan , ZHANG Ming , QIAO Jianliang , LI Jun , MENG Xingkai

2024, 33(3):408-415. DOI: 10.7659/j.issn.1005-6947.2024.03.012

[Abstract](257) [HTML](325) [PDF 696.84 K](576)

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Pancreatic neuroendocrine neoplasms (pNENs) are rare heterogeneous tumors with various malignant potentials. With the widespread application of cross-sectional imaging, the frequency of diagnosis of asymptomatic non-functional pancreatic neuroendocrine neoplasms (NF-pNENs) is increasing annually. However, there are still significant challenges in clinical diagnosis, delayed surgical treatment, and other aspects. Deepening the understanding of NF-pNENs can help improve the clinical diagnostic rate and subsequently implement timely and effective treatment. In this review, the authors discuss the controversial issues in the clinical diagnosis and surgical treatment of NF-pNENs, aiming to provide reference for clinical practice.

13 Role of lipid metabolism disorders in the occurrence and development of pancreatic cancer: a review of research progress

WANG Yunfeng , XIA Junwei , XU Baiying

2024, 33(3):416-423. DOI: 10.7659/j.issn.1005-6947.2024.03.013

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Most pancreatic cancer patients are diagnosed with metastasis already present, leaving few opportunities for surgical treatment, and chemotherapy and radiotherapy showing poor treatment outcomes. There is an urgent need for new treatment modalities. There is a close relationship between disorders of lipid metabolism and the occurrence and development of pancreatic cancer. Lipid metabolism disorders are not only risk factors for the development of pancreatic cancer but also accelerate the progression of pancreatic cancer by inhibiting apoptosis of pancreatic cancer cells and enhancing their metabolism, proliferation, and metastasis. Here, the authors summarize and discuss the progress and focal points of lipid metabolism disorders in pancreatic cancer, aiming to offer insights for relevant research.

14 Postoperative hyperamylasemia following pancreaticoduodenectomy: a research progress review

KAISAIER·Abudouhadier , LIN Hai

2024, 33(3):424-430. DOI: 10.7659/j.issn.1005-6947.2024.03.014

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Postoperative complications after pancreaticoduodenectomy (PD) occur at a high rate of up to 40%, thus early prediction and management of its complications are necessary. Postoperative hyperamylasemia (POH) following PD is considered a predictor of the occurrence rate and severity of early postoperative complications, but due to the unclear mechanism of elevated serum amylase activity, its significance and implications have been interpreted in various ways in recent years. Here, the authors review the concept and development history of POH, its causes and impacts, its relationship with postpancreatectomy acute pancreatitis and postoperative pancreatic fistula, as well as prevention and treatment measures.

15 Advances in clinical diagnosis and treatment of blunt pancreatic trauma

CHEN Jinghao , BAI Yunhu , CHEN Xiyu , LI Xiaodong , YANG Yanling

2024, 33(3):431-438. DOI: 10.7659/j.issn.1005-6947.2024.03.015

[Abstract](123) [HTML](177) [PDF 737.60 K](541)

Abstract:
Blunt pancreatic trauma is not common. Its imaging manifestations are inconspicuous, the concomitant multiple organ injuries often mask each other, and clinical signs are ambiguous, making diagnosis challenging, prone to misdiagnosis or missed diagnosis, resulting in a high mortality rate. The diagnosis of blunt pancreatic trauma should be based on imaging evidence, laboratory tests, comprehensive injury history, and clinical manifestations. Treatment depends on the level and location of the trauma. For low-grade trauma with hemodynamic stability, non-surgical treatment is usually adopted, including fasting, total parenteral nutrition, somatostatin application, acid-suppression therapy, external drainage, pancreatic duct stenting, repeat imaging examinations, and actively managing complications and comorbidities based on the patient's specific condition; non-surgical treatment is generally not recommended for hemodynamically unstable patients. Surgery of high-grade trauma is challenging. Usually, according to the principle of damage control, the pros and cons of the patient's injury severity, physiological state and actual intraoperative situation are weighed, and the appropriate individualized treatment strategy is selected according to the actual capability of the treatment center, with the option of transferring to a regional pancreatic center if necessary. Common complications after blunt pancreatic trauma include pseudocyst and pancreatic fistula. Early use of somatostatin should be employed after surgery to reduce secretion of pancreatic juice and prevent pancreatic fistula. Additionally, percutaneous drainage, endoscopic stent placement, and endoscopic cyst-gastrostomy or cyst-jejunostomy can be used for management. Pseudocyst formation in the pancreas is mainly due to poor postoperative drainage, which can be cured by proper irrigation and puncture catheter drainage, and rarely requires further surgery. The authors elucidate the clinical diagnosis and treatment of blunt pancreatic trauma by combining previous research literature and the treatment experience of their center, aiming to help improve the early diagnosis rate of blunt pancreatic trauma and provide more rational treatment.

16 Current status and problems of ERCP training models, and future development prospects

LI Jinyang , WANG Weichen , XIE Wanying , CHEN Xiaoxiao , TAN Songwen , HE Chao , LIU Wei , XIONG Li

2024, 33(3):439-447. DOI: 10.7659/j.issn.1005-6947.2024.03.016

[Abstract](324) [HTML](169) [PDF 705.11 K](570)

Abstract:
Endoscopic retrograde cholangiopancreatography (ERCP) is a common diagnostic method and therapeutic technique for biliary and pancreatic diseases in clinical practice. In order to shorten the training period and reduce the occurrence of surgical complications due to operational issues, operators need extensive training through training models to reach the level of independently performing a procedure. Here, the authors summarize and analyze the current status and existing problems of different models used at home and abroad: mechanical simulation operation models and computer simulation models have characteristics such as flexibility and visibility, suitable for beginners to understand the procedural flow, but lack realism compared to other models; live animal models have the advantage of complete operational training and management of complications, but they are relatively expensive and do not fully match the human anatomy for training purposes; ex vivo animal models have the advantages of low cost and better realism, suitable for advanced learning and initial training in managing complications. Finally, based on the characteristics of different models, the authors innovatively propose a phased joint ERCP training scheme—the five-stage method, and also suggest new directions for the iterative development of ERCP training models.

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Volume 33,Issue 3,2024 Table of Contents

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