57例胰胃疾病患者空肠营养护理体会

空肠营养是指经鼻置入空肠营养管或空肠造瘘管,提供维持人体代谢所需的营养素的一种方法。随着对胃肠道结构和功能研究的不断深入,人们逐步认识到胃肠道在免疫防御中的重要地位。空肠营养不仅营养素的吸收、利用更符合生理,费用低廉,且助于维持肠黏膜结构和屏障功能的完整性。因此'只要胃肠道有功能就利用它'已成临床医师的共识[1]。

Pixu syndrome grading and its relationship with d-xylose and BT-PABA absorption in 183 patients

AIMS To study the grading of pixu(spleen deficiency)syn- drome and the scientific basis of its relationship with absorption of D-Xylose and BT-PABA. METHODS The present study included 115 cases of chronic su- perficial gastritis,15 cases of chronic atrophic gastritis,19 cases of peptic ulcer and 34 cases of chronic colitis.All of them were diagnosed by endoscopy and biopsies.Chronic gastrointestinal diseases could be categorized into six types,namely,spleen and stomach asthenia syndrome(including asthenia and cold),dishar- mony between liver and stomach,damp and heat of spleen and stomach(bowel)syndrome,spleen-stomach-Yin deficiency,blood stasis and spleen-kidney-Yang deficiency.Grading of these syn- dromes were made with concomitant estimation of d-xylose and BT-PABA tests. RESULTS Patients with chronic gastrointestinal diseases showed diminished urinary level of d-xylosc and that of BT- PABA,as compared with normal,(P<0.05),except those with damp and heat of spleen-bowel syndrome.The excretory rate of d-xylosc was neary normal,while the levels of d-xylose and BT-PABA were lower than those of the normal,(P<0.05-0. 01).In regard to the grading of spleen deficiency and the dishar- mony between liver and stomach syndromes,the excretory rate of D-Xylose decreased gradually(P<0.01 )as the severity of symp- toms increased;in disharmony between liver and stomach syndrome,the excretory rate of BT-PABA also decreased(P<0. 01)as symptoms worsened.These provided scientific proofs for appraisal of the pathophysiology of these syndromes. CONCLUSIONS Changes of d-xylose can reflect the specifici- ty of pixu syndrome whereas changes of BT-PABA reflect the specificity of disharmony between liver and stomach syndrome.

Helicobacter species ribosomal DNA in the pancreas, stomach and duodenum of pancreatic cancer patients

AIM： To determine whether gastric and enteric Helicobacter species are associated with pancreatic cancer. METHODS： Patients with exocrine pancreatic cancer （n = 40）, neuroendocrine cancer （n = 14）, multiple endocrine neoplasia type 1 （n = 8）, and chronic pan- creatitis （n = 5） were studied. Other benign pancreatic diseases （n = 10） and specimens of normal pancreas （n = 7） were included as controls. Pancreatic tissue specimens were analyzed by Helicobacter-specific PCR-assay and products were characterized by denaturing gradient electrophoresis and DNA-sequencing. From a subset of the pancreatic cancer patients, gastric and/or duodenal tissue as well as gallbladder and ductus choledochus tissue were analyzed. Gallbladder and choledochus samples were included as controls. Stomach and duodenum samples were investigated to analyze whether a gastric helicobacter might disseminate to the pancreas in pancreatic cancer patients. Pancreatic specimens were analyzed by Bacteroidesspecific PCR for detecting the translocation of indigenous gut microbes to the diseased pancreas. RESULTS： He/icobacter DNA was detected in pancreas （tumor and/or surrounding tissue） of 75% of patients with exocrine cancer, 57% of patients with neuroendocrine cancer, 38% of patients with multiple endocrine neoplasia, and 60% of patients with chronic pancreatitis. All samples from other benign pancreatic diseases and normal pancreas were negative. Thirtythree percent of the patients were helicobacterpositive in gastroduodenal specimens. Surprisingly, H. bilis was identified in 60% of the positive gastroduodenal samples. All gallbladder and ductus choledochus specimens were negative for helicobacter. Bacteroides PCR-assay was negative for all pancreatic samples. CONCLUSION： Helicobacter DNA commonly detected in pancreatic cancer suggests a possible role of the emerging pathogens in the development of chronic pancreatitis and pancreatic cancer.

Heterotopic pancreas in the stomach:A case report and literature review

Ectopic pancreas is defined as pancreatic tissue found outside the usual anatomic location of the pancreas. It is often an incidental finding and can be found at different sites in the gastrointestinal tract. It may become clinically evident when complicated by pathologic changes such as inflammation, bleeding, obstruction, and malignant transformation. In this report, a 40 years old woman with epigastric pain due to ectopic pancreatic tissue in the stomach is described. The difficulty of making an ac- curate diagnosis is highlighted. The patient has remained free of symptoms since she underwent wedge resection of the lesion three years ago. Frozen sections may help in deciding the extent of resection intraoperatively. Al- though ectopic pancreas is rare, it should be considered in the differential diagnosis of a submucosal gastric tumour.

Unusual gastric and pancreatic metastatic renal cell carcinoma presentation 10 years after surgery and immunotherapy: A case report and a review of literature

Renal cell carcinoma （RCC） is the most common renal tumor, accounting for 2%-3% of all malignancies. Though RCC is known to spread hematogenously, isolated RCC metastasis to the stomach is a rare event. In this article, we describe the clinical course of a patient who developed a pancreatic recurrence of RCC and 1 year later a gastric recurrence of RCC treated 10 years ago with a resection and interleukin-2 （IL-2）. Accumulating evidence indicates that metastatic involvement of the pancreas and stomach should be suspected in any patient with a history of RCC who presents with gastrointestinal symptoms even 10 years after RCC resection and immunotherapy.

Robotic-assisted laparoscopic resection of ectopic pancreas in the posterior wall of gastric high body: Case report and review of the literature

Minimally invasive surgery has revolutionized the treatment of gastrointestinal tumors. Submucosal tumors of the stomach can be resected using laparoscopic techniques. We report here a case of ectopic pancreas tissue in the gastric wall that was removed using robotic-assisted laparoscopic resection. The patient was a 15-year-old female who presented with abdominal discomfort and tarry stools. Laboratory analysis showed iron deficiency anemia. Preoperative endoscopy revealed a submucosal lesion in the posterior wall of the gastric high body. Intraoperative upper endoscopy clearly located the lesion. A robotic-assisted laparoscopic wedge resection of the putative gastric submucosal tumor was performed. The pathology results showed an ectopic pancreas. The patient had an uneventful recovery and we believe that this is a valid treatment option for this benign condition.

Mechanism for Src activation by the CCK2 receptor:Patho-physiological functions of this receptor in pancreas

AIM： TO investigate in vivo, whether CCK2 receptors （CCK2R） regulate proteins known to play a crucial role in cell proliferation and cancer development and analyse in vitro the molecular mechanisms that lead to Src activation; in particular, to identify the domains within the CCK2R sequence that are implicated in this activation. METHODS： The expression and activation of Src and ERK were studied in vivo using immunofluorescence and western-blot techniques. We used pancreatic tissues derived from wild type or Elas-CCK2 mice that expressed the CCK2R in pancreatic acini, displayed an increased pancreatic growth and developed preneoplastic lesions. The pancreatic tumor cell line AR4-2J expressing the endogenous CCK2R or COS-7 cells transiently transfected with wild type or mutant CCK2R were used as in vitro models to study the mechanism of Src activation. Src activation was measured by in vitro kinase assays, ERK activation by western blot using antiphospho-ERK antibodies and the involvement of Src in gastrin-induced cell proliferation by MTT test. RESULTS： We showed in vivo that the targeted CCK2R expression in the pancreas of Elas-CCK2 mice, led to the activation of Src and the ERK pathway. Src was activated upstream of the ERK pathway by the CCK2R in pancreatic tumoral cells and contributed to the proliferative effects mediated by this receptor. In vitro results demonstrated that activation of the Src/ERK pathway by the CCK2R required the NPXXY motif, located within the CCK2R sequence at the end of the 7^th transmembrane domain, and suggested the putative role of Gq in this mechanism. CONCLUSION： Deregulation of the Src/ERK pathway by the CCK2R might represent an early step that contributes to cell proliferation, formation of preneoplastic lesions and pancreatic tumor development.

Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy:A review of the literature and critical reappraisal of the implicated pathomechanism

Pylorus-preserving pancreaticoduodenectomy （PPPD） is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying （DGE） comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/IVledline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy （PD） vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported （but not yet tested in largescale studies） modification, that is, PPPD with antecolic duodenojejunostomy.

Sporadic versus hereditary gastrinomas of the duodenum and pancreas: Distinct clinico-pathological and epidemiological features

Gastrinomas are defined as gastrin secreting tumors that are associated with Zollinger-Ellison syndrome （ZES）. ZES is characterized by elevated fasting gastrin serum levels, positive secretin stimulation test and clinical symptoms such as recurrent peptic ulcer disease, gastroesophageal reflux disease and occasional diarrhea. Genetically, nonhereditary （sporadic） gastrinomas are distinguished from hereditary gastrinomas, which are associated with multiple endocrine neoplasia type 1 （MEN1） syndrome. In general, duodenal gastrinomas are small and solitary if they are sporadic and multiple as well as hereditary. The sporadic gastrinomas occur in the duodenum or in the pancreas while the hereditary gastrinomas almost all occur in the duodenum. Our series of 77 sporadic duodenal neuroendocrine tumors （NETs） includes 18 patients （23.4%） with gastrinomas and ZES. Of 535 sporadic NETs in the pancreas collected from the NET archives of the departments of pathology in Zürich, Switzerland, and Kiel, Germany, 24 patients （4.5%） suffered from sporadic pancreatic gastrinomas and ZES. These NETs have to be distinguished from tumors with immunohistochemical positivity for gastrin but without evidence of ZES. An additional 19 patients suffered from MEN1 and ZES. These patients showed exclusively duodenal gastrinomas, but not pancreatic gastrinomas. The prognosis of sporadic and MEN1- associated duodenal gastrinomas is better than that of pancreatic gastrinomas, since they progress slowly to liver metastasis. In summary, sporadic and MEN1- associated gastrinomas in the duodenum and pancreas show different clinico-pathological and genetic features. The incidence of sporadic duodenal gastrin-producing tumors is increasing, possibly due to optimized diagnostic procedures. In contrast, pancreatic MEN1- associated gastrinomas seem to be extremely rare. A considerable subset of tumors with immunohistochemical expression of gastrin but without evidence of ZES should be designated as functionally inactive NETs expressing gastrin, but not as gastrinomas.

Mucinous cyst exhibiting severe dysplasia in gastric heterotopic pancreas associated withe gastrointestinal stromal tumour

Heterotopic pancreatic tissue within the stomach is rare and dysplasia within heterotopic pancreatic tissue is very rare. We present the first report of a patient with concurrent occurrence of heterotopic pancreas in the stomach with a gastrointestinal stromal tumour.

Gastrointestinal manifestations of endocrine disease

The hormonal interactions among the systems throughout the body are not fully understood; many vague clinical symptoms may in fact be manifestations of underlying endocrine diseases. The aim of the following review is to discuss gastrointestinal manifestations of surgically correctable endocrine diseases, focusing on abnormalities of thyroid function, cancer and finally autoimmune diseases. We also review manifestations of pancreatic endocrine tumors, and multiple endocrine neoplasia.