Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy

BACKGROUND Pancreatic fistula is one of the most serious complications after pancreatoduodenectomy for treating any lesions at the pancreatic head. For years, surgeons have tried various methods to reduce its incidence. AIM To investigate and emphasize the clinical outcomes of Blumgart anastomosis compared with traditional anastomosis in reducing postoperative pancreatic fistula. METHODS In this observational study, a retrospective analysis of 291 patients who underwent pancreatoduodenectomy, including Blumgart anastomosis (201 patients) and traditional embedded pancreaticojejunostomy (90 patients), was performed in our hospital. The preoperative and perioperative courses and longterm follow-up status were analyzed to compare the advantages and disadvantages of the two methods. Moreover, 291 patients were then separated by the severity of postoperative pancreatic fistula, and two methods of pancreaticojejunostomy were compared to detect the features of different anastomosis. Six experienced surgeons were involved and all of them were proficient in both surgical techniques.RESULTS The characteristics of the patients in the two groups showed no significant differences, nor the preoperative information and pathological diagnoses. The operative time was significantly shorter in the Blumgart group (343.5 ± 23.0 vs 450.0 ± 40.1 min, P = 0.028), as well as the duration of pancreaticojejunostomy drainage tube placement and postoperative hospital stay (12.7 ± 0.9 d vs 17.4 ± 1.8 d, P = 0.031;and 21.9 ± 1.3 d vs 28.9 ± 1.3 d, P = 0.020, respectively). The overall complications after surgery were much less in the Blumgart group than in the embedded group (11.9% vs 26.7%, P = 0.002). Patients who underwent Blumgart anastomosis would suffer less from severe pancreatic fistula (71.9% vs 50.0%, P = 0.006), and this pancreaticojejunostomy procedure did not have worse influences on long-term complications and life quality. Thus, Blumgart anastomosis is a feasible pancreaticojejunostomy procedure in pancreatoduodenectomy surgery. It is safe in causing less postoperative complications, especially pancreatic fistula, and thus shortens the hospitalization duration. CONCLUSION Surgical method should be a key factor in reducing pancreatic fistula, and Blumgart anastomosis needs further promotion.

Pancreatic metastasis of renal cell carcinoma

BACKGROUND： Renal cell carcinoma （RCC） is a common cancer, but pancreatic metastasis of RCC is unusual. Because of the rarity and peculiarity, pancreatic lesions from RCC metastasis were described mostly in case reports which highlight the importance of a systematic analysis of this clinical condition. DATA SOURCES： Data of 7 patients with pancreatic metastasis of RCC treated in the Peking Union Medical College Hospital were extracted and 193 similar patients reported in the past 10 years from the literature were analyzed. Epidemiological, pathological and follow-up information were investigated. Po- tential prognostic factors were compared with corresponding data reported 10 years ago. RESULTS： Multivariate Cox regression showed that asymp- tomatic metastasis and surgical procedure were independent factors associated with better survival. Compared with the data reported 10 years ago, follow-up of RCC patients has been emphasized in recent years, and atypical surgery is frequently used since it has similar effect as typical surgery on tumor resection while it is able to preserve more pancreatic function. CONCLUSION： Surgical treatment should be an option as long as the pancreatic metastasis of RCC is resectable.

Recent studies of 5-fluorouracil resistance in pancreatic cancer

Resistance to 5-fluorouracil(5-FU), an important anticancer drug, is a serious challenge in the treatment of pancreatic cancer. Equilibrative nucleoside transporter 1 and multidrug-resistance protein(MRP) 5 and MRP8, rather than P-glycoprotein, play important roles in 5-FU transport. Thymidylate synthase, dihydropyrimidine dehydrogenase, methylenetetrahydrofolate reductase and thymidine phosphorylase are four key enzymes involved in 5-FU metabolism. Other metabolic enzymes, including uridine monophosphate synthetase, also contribute to chemoresistance. Intracellular signaling pathways are an integrated network, and nuclear factor kappa-light-chain-enhancer of activated B cells, AKT and extracellular signal-regulated kinases are signaling pathways that are particularly relevant to 5-FU resistance. In addition, recent reports indicate that STAT-3 is a crucial survival protein. Proteomic assays provide a powerful tool for identifying target proteins and understanding the role of micro RNAs and stromal factors to facilitate the development of strategies to combat 5-FU resistance.

Diagnostic accuracy of K-ras mutation for pancreatic carcinoma:a meta-analysis

BACKGROUND:The conventional tests for the diagnosis of early stage pancreatic carcinoma are not acceptable.This metaanalysis is to evaluate the accuracy of K-ras mutation for the diagnosis of pancreatic carcinoma.DATA SOURCES:A systemic search of all relevant literature was performed in Web of Science,EMBASE,Cochrane Database,and MEDLINE(PubMed as the search engine) prior to June 1,2011.Thirty-four studies fulfilled the inclusion criteria and data were pooled for analysis.RESULTS:The pooled estimates for K-ras mutation in diagnosis of pancreatic carcinoma were as follows:sensitivity 0.68(95% CI:0.66-0.71),specificity 0.87(95% CI:0.85-0.88),positive likelihood ratio 4.54(95% CI:3.47-5.94),negative likelihood ratio 0.37(95% CI:0.30-0.44) and diagnostic odds ratio 14.90(95% CI:10.02-22.15).Summary receiver operating characteristic analysis demonstrated that the maximum joint sensitivity and specificity was 0.79,and the overall area under the curve was 0.86.CONCLUSIONS:Diagnostic accuracy of K-ras mutation was not superior to that of conventional tests.Therefore,K-ras mutation analysis alone is not recommended for the diagnosis of pancreatic carcinoma.

Risk factors for the occurrence of insulinoma: a case-control study

BACKGROUND: The etiology of insulinoma is poorly understood. Few studies investigated the possible roles of environmental factors and lifestyle in the pathogenesis of insulinoma. The aim of this study is to identify risk factors associated with occurrence of insulinoma in the Chinese population. METHODS: This study consisted of 196 patients with insulinoma and 233 controls. Demographic information of the patients and controls and risk factors of the disease were analyzed. Univariate and unconditional multivariable logistic regression analyses were made to estimate odds ratios (ORs) and possible risk factors. RESULTS: Approximately 68.88% (135/196) of the patients were from rural areas in contrast to 10.30% (24/233) of the controls (P【0.0001). This difference was confirmed by the multivariate analysis (OR=4.950; 95% CI: 2.928-8.370). Family history of pancreatic endocrine tumor (OR=16.754; 95% CI: 2.125-132.057) and other cancers (OR=2.360; 95% CI: 1.052-5.291) was also related to a high-risk population of insulinoma. CONCLUSION: Rural residents or people who have a family history of pancreatic endocrine tumor and other cancers are a high-risk population of insulinoma.

Prognostic significance of epidermal growth factor-like domain 7 in pancreatic cancer

BACKGROUND： Recent studies have shown the clinical significance of epidermal growth factor-like domain 7（EGFL7）in a variety of cancers. However, the relationship between EGFL7 and the prognosis of pancreatic cancer（PC） remains unclear. The present study was undertaken to investigate the role of EGFL7 in the prognosis of PC.METHODS： The expression of EGFL7 in nine PC cell lines was first determined by Western blotting analysis. Tissue microarray-based immunohistochemical staining was performed in paired formalin-fixed paraffin-embedded tumor and non-tumor samples from 83 patients with PC. Finally,correlations between EGFL7 expression and clinicopathological variables as well as overall survival were evaluated.RESULTS： EGFL7 was widely expressed in all PC cell lines tested.EGFL7 expression in tumor tissues was significantly higher than that in non-tumor tissues（P0.040）. In addition, univariate analysis revealed that high EGFL7 expression in tumor tissues was significantly associated with poor overall survival,accompanied by several conventional clinicopathological variables, such as gender, histological grade and lymph node metastasis. In a multivariate Cox regression test, EGFL7 expression was identified as an independent marker for longterm outcome of PC.CONCLUSION： Our data showed that EGFL7 is extensively expressed in PC and that EGFL7 is associated with poor prognosis.

Surgical treatment of chronic pancreatitis

Objective: To summarize the experience in the surgi- cal treatment of chronic pancreatitis. Methods: 189 patients with pancreatitis admitted from May 1983 to August 1999 to our hospital were reviewed. Results: 136 (72 %) patients received surgical treat- ment including pancreatoduodenectomy (15 pa- tients), distal pancreatectomy (12), internal drain- age of pancreatic pseudocyst (28), side-to-side pan- creaticojejunostomy (16), relief of biliary stenosis (58), and pancreatic biopsy (7). Pain was relieved in 97.8 % of the patients, and the complication rate was 1.5%. Conclusions: It is crucial to select various surgical strategies at a proper time for chronic pancreatitis patients. Patients with chronic pancreatitis compli- cated by dilation or obstruction of the pancreatic duct or with biliary pancreatitis should be operated on in early stages, whereas those with other types of chronic pancreatitis should receive the therapy focu- sing on the alleviation of their symptoms, not on ear- ly surgical intervention. The timing and modality of surgery are important in improving the life quality of the patients and changing their natural history of the disease.

Plasminogen Activator Inhibitor I as a Poor Prognostic ndicator in Resectable Pancreatic Ductal Adenocarcinoma

Background:Plasminogen activator inhibitor 1 (PAI-I)was previously established to impact several phenotypes in many kinds of cancer, including pancreatic cancer.However,its prognostic significance in pancreatic ductal adenocarcinoma (PDAC)needs support of further evidence.This study was designed to address the issue. Methods:PAI-1 expression was detected by tissue microarray-based immunohistochemical staining in formalin-fixed paraffin-embedded specimens from 93 PDAC patients with surgical resection from September 2004 to December 2008.Its relationships with clinicopathologic variables and tumor-specific survival (TSS)were further evaluated using Chi-square,Kaplan-Meier,log-rank,as well as Cox regression analyses. Results:Expression of PAI-1 was much higher in tumor than that in nontumor tissues,based on comparison of all samples and 74 matched ones (95 [47.5,180]vs.80 [45,95],Z=-2.439,P=0.015 and 100 [46.9,182.5]vs.80 [45,95],Z=-2.594,P =0.009,respectively).In addition,tumoral PAI-1 expression was positively associated with N stage (22/35 for N1 vs.21/51 for N0,x^2 =3.903,P=0.048).Univariate analyses showed that TSS of patients with high PAI-1 tumors was significantly poorer than that of those with low PAI-1 tumors (log rank value =19.00,P <0.0001).In multivariate Cox regression test,PAI-1 expression was identified as an independent predictor for long-term prognosis ofresectable PDAC (hazard ratio =2.559,95% confidence interval =1.499-4.367,P =0.001). Conclusion:These results suggest that expression of PAI-1 is upregulated in PDAC and might serve as a poor prognostic indicator.