区域化疗加转流术治疗未切除胰腺癌

尽管诊断技术的发展使得胰腺癌的确诊率有了显著提高,但手术切除率仍很低,对约80％左右未能切除的病例,寻求更理想的方法治疗,提高其生存期和生存质量,是临床面对的难点课题。

急性重症胰腺炎并发下腔静脉溃破大出血2例(摘要)

急性重症胰腺炎引起出血的原固很复杂,主要是因各种蛋白分解酶及磷脂酶对血管及其周围的作用,尤其是通过激活弹力蛋白酶和磷脂酶A引起血管弹力纤维的溶解,导致胰腺及其周围血管的侵蚀性破溃大出血,但并发下腔静脉破溃大出血很少见,国内尚未见报道。本文介绍2例急性重症性胰腺炎病人,在术中分离清除胰腺后腹膜间隙时并发大出血,检查发现均为下腔静脉受侵蚀破溃而引发大出血,出血量都达到2000ml。

Pancreatic fistula after pancreatectomy:Evolving definitions,preventive strategies and modern management

Pancreatic resection is the treatment of choice for pancreatic malignancy and certain benign pancreatic disorders. However, pancreatic resection is technically a demanding procedure and whereas mortality after a pancreaticoduodenectomy is currently < 3%-5% in experienced high-volume centers, post-operative morbidity is considerable, about 30%-50%. At present, the single most significant cause of morbidity and mortality after pancreatectomy is the development of pancreatic leakage and fistula (PF). The occurrence of a PF increases the length of hospital stay and the cost of treatment, requires additional investigations and procedures, and can result in life-threatening complications. There is no universally accepted definition of PF that would allow standardized reporting and proper comparison of outcomes between different centers. However, early recognition of a PF and prompt institution of appropriate treatment is critical to the prevention of potentially devastating consequences. The present article, reviews the evolution of post resection pancreatic fistula as a concept, and discusses evolving definitions, the current preventive strategies and the management of this problem.

Aggressive behaviour of solid-pseudopapillary tumor of the pancreas in adults:A case report and review of the literature

Solid-pseudopapillary tumor (SPT) is a rare neoplasm of the pancreas that usually occurs in young females. It is generally considered a low-grade malignant tumor that can remain asymptomatic for several years. The occurrence of infiltrating varieties of SPT is around 10%-15%. Between 1986 and 2006, 282 cystic tumors of the pancreas were observed. Among them a SPT was diagnosed in 8 patients (2.8%) with only one infiltrating variety. This was diagnosed in a 49-year-old female 13 years after the sonographic evidence of a small pancreatic cystic lesion interpreted as a pseudocyst. The tumor invaded a long segment of the portal- mesenteric vein confluence, and was removed with a total pancreatectomy, resection of the portal vein and reconstruction with the internal jugular vein. Histological examination confirmed the R-0 resection of the primary SPT, although a vascular invasion was demonstrated. The postoperative course was uneventful, but 32 mo after surgery the patient experienced diffuse liver metastases. Chemotherapy with different drugs was started. The patient is alive and symptom-free, with stable disease, 75 mo after surgery. Twenty-five patients with invasion of the portal vein and/or of mesenteric vessels were retrieved from the literature, 16 recent patients with tumor relapse after potentially curative resection were also retrieved. The best treatment remains a radical resection whenever possible, even in locally advanced or metastatic disease. The role of chemotherapy, and/or radiotherapy, is still to be defined.

Ductal adenocarcinoma of the pancreatic head:A focus on current diagnostic and surgical concepts

Complete surgical resection still remains the only possibility of curing pancreatic cancer,however,only 10% of patients undergo curative surgery.Pancreatic resection currently remains the only method of curing patients,and has a 5-year overall survival rate between 7%-34% compared to a median survival of 3-11 mo for unresected cancer.Pancreatic surgery is a technically demanding procedure requiring highly standardized surgical techniques.Nevertheless,even in experienced hands,perioperative morbidity rates(delayed gastric emptying,pancreatic fistula etc.) are as high as 50%.Different strategies to reduce postoperative morbidity,such as different techniques of gastroenteric reconstruction(pancreatico-jejunostomy vs pancreatico-gastrostomy),intraoperative placement of a pancreatic main duct stent or temporary sealing of the main pancreatic duct with fibrin glue have not led to a significant improvement in clinical outcome.The perioperative application of somatostatin or its analogues may decrease the incidence of pancreatic fistulas in cases with soft pancreatic tissue and a small main pancreatic duct(< 3 mm).The positive effects of external pancreatic main duct drainage and antecolic gastrointestinal reconstruction have been observed to decrease the rate of pancreatic fistulas and delayed gastric emptying,respectively.Currently,the concept of extended radical lymphadenectomy has been found to be associated with higher perioperative morbidity,but without any positive impact on overall survival.However,there is growing evidence that portal vein resections can be performed with acceptable low perioperative morbidity and mortality but does not achieve a cure.

Risk factors of pancreatic leakage after pancreaticoduodenectomy

AIM: To analyze the risk factors for pancreatic leakage after pancreaticoduodenectomy (PD) and to evaluate whether duct-to-mucosa pancreaticojejunostomy could reduce the risk of pancreatic leakage. METHODS: Sixty-two patients who underwent PD at our hospital between January 2000 and November 2003 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, and gastric cancer. Standard PD was performed for 25 cases, PD with extended lymphadenectomy for 27 cases, pylorus-preserving PD for 10 cases. A duct-to-mucosa pancreaticojejunostomy was performed for patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy for patients with a soft pancreas and a non-dilated duct. Patients were divided into two groups according to the incidence of postoperative pancreaticojejunal anastomotic leakage: 10 cases with leakage and 52 cases without leakage. Seven preoperative and six intraoperative risk factors with the potential to affect the incidence of pancreatic leakage were analyzed with SPSS10.0 software. Logistic regression was then used to determine the effect of multiple factors on pancreatic leakage. RESULTS: Of the 62 patients, 10 (16.13%) were identified as having pancreatic leakage after operation. Other major postoperative complications included delayed gastric emptying (eight patients), abdominal bleeding (four patients), abdominal abscess (three patients) and wound infection (two patients). The overall surgical morbidity was 43.5% (27/62). The hospital mortality in this series was 4.84% (3/62), and the mortality associated with pancreatic fistula was 10% (1/10). Sixteen cases underwent duct-to-mucosa pancreaticojejunostomy and 1 case (1/16, 6.25%) devel-oped postoperative pancreatic leakage, 46 cases underwent invagination pancreaticojejunostomy and 9 cases (9/46, 19.6%) developed postoperative pancreatic leakage. General risk factors including patient age, gender, history of jaundice, preoperative nutrition, pathological diagnosis and the length of postoperative stay were similar in the two groups. There was no statistical difference in the incidence of pancreatic leakage between the patients who received the prophylactic use of octreotide after surgery and the patients who did not undergo somatostatin therapy. Moreover, multivariate logistic regression analysis showed that none of the above factors seemed to be associated with pancreatic fistula. Two intraoperative risk factors, pancreatic duct size and texture of the remnant pancreas, were found to be significantly associated with pancreatic leakage. The incidence of pancreatic leakage was 4.88% in patients with a pancreatic duct size greater than or equal to 3 mm and was 38.1% in those with ducts smaller than 3 mm (P = 0.002). The pancreatic leakage rate was 2.94% in patients with a hard pancreas and was 32.1% in those with a soft pancreas (P = 0.004). Operative time, blood loss and type of resection were similar in the two patient groups. The incidence of pancreatic leakage was 6.25% (1/16) in patients with duct-to-mucosa anastomosis, and was 19.6% (9/46) in those with traditional invagination anastomosis. Although the difference of pancreatic leakage between the two groups was obvious, no statistical signific-ance was found. This may be due to the small number of patients with duct-to-mucosa anastomosis. By further analyzing with multivariate logistic regression, both pancreatic duct size and texture of the remnant pancreas were demonstrated to be independent risk factors (P= 0.007 and 0.017, OR = 11.87 and 15.45). Although anastomotic technique was not a significant factor, pancreatic leakage rate was much less in cases that underwent duct-to-mucosa pancreaticojejunostomy. CONCLUSION: Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Duct-to-mucosa pancreaticojejunostomy, as a safe and useful anastomotic technique, can reduce pancreatic leakage rate after PD.

Surgical outcome of adenosquamous carcinoma of the pancreas

Adenosquamous carcinoma is rare,accounting for 3%-4% of all pancreatic carcinoma cases. These tumors are characterized by the presence of variable proportions of mucin-producing glandular elements and squamous components,the latter of which should account for at least 30% of the tumor tissue. Recently,several reports have described cases of adenosquamous carcinoma of the pancreas. However,as the number of patients who undergo resection at a single institute is limited,large studies describing the clinicopathological features,therapeutic management,and surgical outcome for adenosquamous carcinoma of the pancreas are lacking. We performed a literature review of English articles retrieved from Medline using the keywords 'pancreas' and 'adenosquamous carcinoma'. Additional articles were obtained from references within the papers identif ied by the Medline search. Our subsequent review of the literature revealed that optimal adjuvant chemotherapy and/or radiotherapy regimens for adenosquamous carcinoma of the pancreas have not been established,and that curative surgical resection offers the only chance for long-term survival. Unfortunately,the prognosis of the 39 patients who underwent pancreatic resection for adenosquamous carcinoma was very poor,with a 3-year overall survival rate of 14.0% and a median survival time of 6.8 mo. Since the postoperative prognosis of adenosquamous carcinoma of the pancreas is currently worse than that of pancreatic adenocarcinoma,new adjuvant chemotherapies and/or radiation techniques should be investigated as they may prove indispensible to the improvement of surgical outcomes.

Clinical Study on Suspension Pancreatic-Duct-Jejunum End-to-Side Continuous Suture Anastomosis in Pancreaticoduodenectomy

Objective To study the influence of Suspension Pancreatic-Duct-Jejunum End-to-Side Continuous Suture Anastomosis （SPDJCS） on the incidence of pancreatic fistula after pancreaticoduodenectomy, and to analyze its applicability, safety, and efficacies. Methods A prospective controlled trial was conducted with 165 cases receiving pancreati- coduodenectomy in the Department of Hepatopancreatobiliary Surgery from January 2010 to May 2012. The patients were divided into Group A （end-to-end/end-to-side invaginated anastomosis, n=52）, Group B （end-to-side mucosal anastomosis, n=48）, and Group C （SPDJCS, n=65）. The preoperative data, intra- operative data, and operative outcomes （incidence of pancreatic fistula, operation time, intraoperative blood loss, peritoneal drainage, peritoneal hemorrhage, peritoneal abscess, delayed gastric emptying, pulmonary infection, postoperative infection, blood transfusion, and perioperative mortality） were com- pared among the 3 groups. Results The total incidence of pancreatic fistula was 13.9% （23/165） in all the 165 patients. The inci- dence in Group A and Group B was 23.1% （12/52） and 18.8% （9/48）, both higher than that in Group C [3.1% （2/65）, both P〈0.05]. Group C showed significantly better outcomes than group A and B in terms of the opera- tion time （5.5±1.2 hours vs. 6.1±1.1 hours, 5.5±1.2 hours vs. 6.3±1.5 hours）, volume of blood loss （412.0±205.0 mL vs. 525.0±217.0 mL, 412.0±205.0 mL vs. 514.0±217.0 mL）, and postoperative drainage amount of plasma tubes （175.0±65.0 mE vs. 275.0±80.0 mL, 175.0±65.0 mL vs. 255.0±75.0 mL） （all P〈0.05）, while Group A and Group B displayed no difference in these aspects （P〉0.05）. As complications other than pancreatic fistula were concerned, the three groups were not different from each other （P〉0.05）. Conclusions SPDJCS may have the effect of reducing the incidence of pancreatic fistula after pan- creaticoduodenectomy. It could be safe, practical and convenient technique of anastomosis for pancreaticoje- junostomy.

Clinical value of serum CA19-9 levels in evaluating resectability of pancreatic carcinoma

AIM:To evaluate the clinical value of serum CA19-9 levels in predicting the respectability of pancreatic carcinoma according to receiver operating characteristic(ROC) curve analysis. METHODS:Serum CA19-9 levels were measured in 104 patients with pancreatic cancer which were possible to be resected according to the imaging. ROC curve was plotted for the CA19-9 levels. The point closest to the upper left-hand corner of the graph were chosen as the cut-off point. The sensitivity,specificity,positive and negative predictive values of CA19-9 at this cut-off point were calculated. RESULTS:Resectable pancreatic cancer was detected in 58(55.77%) patients and unresectable pancreatic cancer was detected in 46(44.23%) patients. The area under the ROC curve was 0.918 and 95% CI was 0.843-0.992. The CA19-9 level was 353.15 U/mL,and the sensitivity and specificity of CA19-9 at this cut-off point were 93.1% and 78.3%,respectively. The positive and negative predictive value was 84.38% and 90%,respectively. CONCLUSION:Preoperative serum CA19-9 level is a useful marker for further evaluating the resectability of pancreatic cancer. Obviously increased serum levels of CA19-9(> 353.15 U/mL) can be regarded as an ancillary parameter for unresectable pancreatic cancer.

A survey of ampullectomy practices

AIM： To investigate the endoscopic ampullectomy practices of expert biliary endoscopists. METHODS： An anonymous expert biliary endoscopists practices. survey was mailed to 79 to assess ampullectomy RESULTS： Forty six （58%） biliary endoscopists returned the questionnaire. Of these, 63% were in academia and in practice for an average of 16.4 years （± 8.6）. Endoscopists performed an average of 1.1 （± 0.8） ampullectomies per month. Prior to ampullectomy, endoscopic ultrasound was ＂always＂ utilized by 67% of respondents vs ＂sometimes＂ in 31% of respondents. Empiric biliary sphincterotomy was not utilized uniformly, only 26% ＂always＂ and 37% ＂sometimes＂ performed it prior to resection. Fifty three percent reported ＂never＂ performing empiric pancreatic sphincterotomy prior to ampullectomy. Practitioners with high endoscopic retrograde cholangiopancreatography volumes were the most likely to perform a pancreatic sphincterotomy （OR = 10.9; P = 0.09）. Participants overwhelmingly favored ＂always＂ placing a prophylactic pancreatic stent, with 86% placing it after ampullectomy rather than prior to resection （23%）. Argon plasma coagulation was the favored adjunct modality （83%） for removal of residual adenomatous tissue. Practitioners uniformly （100%） preferred follow-up examination to be within 6 mo postmpullectomy.CONCLUSION： Among biliary experts, there is less variation in ampultectomy practices than is reflected in the literature.

Multifocal intraductal papillary mucinous neoplasm of the pancreas-A case report

Cystic neoplasms of the pancreas are relatively rare, comprising 10 percent of pancreatic cysts and only 1 percent of pancreatic cancers. Cystic neoplasms include mucinous cystic neoplasms, serous cystadenomas, papillary cystic tumors, cystic islet cell tumors and intraductal papillary mucinous neoplasms of the pancreas (IPMNs). IPMN was first described in 1982. It has been most commonly described in 60 to 70 years old males, and represents a relatively ''new'' but increasingly recognized disease. The improvement and widespread use of modern imaging equipments and heightened awareness of physicians contribute to the increasing incidence of IPMN. The majority of IPMNs are located in the pancreatic head (75%) while the rest involves the body/tail regions. Multifocal IPMNs have been hypothesized, but the true presence of multifocality is unknown. Here we present a 72-yearold male diagnosed with IPMN (carcinoma in situ ) in the pancreatic head and a branch duct type IPMN (duct atypia) in the pancreatic body and tail. The patient underwent a Whipple intervention and a distal pancreatectomy. A three-year disease-free survival has been observed so far.

Conservative resection for benign tumors of the proximal pancreas

AIM:To evaluate the safety and long-term prognosis of conservative resection (CR) for benign or borderline tumor of the proximal pancreas.METHODS: We retrospectively analyzed 20 patients who underwent CR at the Second Affi liated Hospital of Zhejiang University School of Medicine between April 2000 and October 2008. For pancreaticojejunostomy, a modified invagination method, continuous circular invaginated pancreaticojejunostomy (CCI-PJ) was used. Modified continuous closed lavage (MCCL) was performed for patients with pancreatic fistula.RESULTS: The indications were: serous cystadenomas in eight patients, insulinomas in six, non-functional islet cell tumors in three and solid pseudopapillary tumors in three. Perioperative mortality was zero and morbidity was 25%. Overall, pancreatic fistula was present in 25% of patients. At a mean follow up of 42.7 mo, all patients were alive with no recurrence and no new-onset diabetes mellitus or exocrine dysfunction.CONCLUSION: CR is a safe and effective procedure for patients with benign tumors in the proximal pancreas, with careful CCI-PJ and postoperative MCCL.

Five-year survival following a medial pancreatectomy for an invasive ductal carcinoma from the body of the pancreas

We report a rare case of a patient who survived for 5 years after undergoing a medial pancreatectomy for invasive ductal carcinoma originating from the body of the pancreas. A 63-year-old woman was diagnosed as a small cancer of the pancreatic body, and surgery was performed. Even though the tumor was a carcinoma, its small size prompted us to perform a medial pancreatectomy with regional lymph nodes dissection. Additional chemoradiation was performed and, five years after surgery, the patient is well with no signs of recurrence. Medial pancreatectomy for invasive ductal carcinoma has not ever been reported. Furthermore, long-term survival after a lumpectomy for invasive ductal carcinoma has never been reported in the literatures. The current case suggests that long-term survival in patients with invasive ductal carcinoma of the pancreas may be associated with the pathological or biological features of pancreatic carcinoma.

National trends in resection of the distal pancreas

AIM:To investigate national trends in distal pancreatectomy(DP) through query of three national patient care databases.METHODS:From the Nationwide Inpatient Sample(NIS,2003-2009),the National Surgical Quality Improvement Project(NSQIP,2005-2010),and the Surveillance Epidemiology and End Results(SEER,2003-2009) databases using appropriate diagnostic and procedural codes we identified all patients with a diagnosis of a benign or malignant lesion of the body and/or tail of the pancreas that had undergone a partial or distal pancreatectomy.Utilization of laparoscopy was defined in NIS by the International Classification of Diseases,Ninth Revision correspondent procedure code;and in NSQIP by the exploratory laparoscopy or unlisted procedure current procedural terminology codes.In SEER,patients were identified by the International Classification of Diseases for Oncology,Third Edition diagnosis codes and the SEER Program Code Manual,third edition procedure codes.We analyzed the databases with respect to trends of inpatient outcome metrics,oncologic outcomes,and hospital volumes in patients with lesions of the neck and body of the pancreas that underwent operative resection.RESULTS:NIS,NSQIP and SEER identified 4242,2681 and 11 082 DP resections,respectively.Overall,laparoscopy was utilized in 15%(NIS) and 27%(NSQIP).No significant increase was seen over the course of the study.Resection was performed for malignancy in 59%(NIS) and 66%(NSQIP).Neither patient Body mass index nor comorbidities were associated with operative approach(P = 0.95 and P = 0.96,respectively).Mortality(3% vs 2%,P = 0.05) and reoperation(4% vs 4%,P = 1.0) was not different between laparoscopy and open groups.Overall complications(10% vs 15%,P < 0.001),hospital costs [44 741 dollars,interquartile range(IQR) 28 347-74 114 dollars vs 49 792 dollars,IQR 13 299-73 463,P = 0.02] and hospital length of stay(7 d,IQR 4-11 d vs 7 d,IQR 6-10,P < 0.001) were less when laparoscopy was utilized.One and two year survival after resection for malignancy were unchanged over the course of the study(ductal adenocarinoma 1-year 63.6% and 2-year 35.1%,P = 0.53;intraductal papillary mucinous neoplasm and nueroendocrine 1-year 90% and 2-year 84%,P = 0.25).The majority of resections were performed in teaching hospitals(77% NIS and 85% NSQIP),but minimally invasive surgery(MIS) was not more likely to be used in teaching hospitals(15% vs 14%,P = 0.26).Hospitals in the top decile for volume were more likely to be teaching hospitals than lower volume deciles(88% vs 43%,P < 0.001),but were no more likely to utilize MIS at resection.Complication rate in teaching and the top decile hospitals was not significantly decreased when compared to non-teaching(15% vs 14%,P = 0.72) and lower volume hospitals(14% vs 15%,P = 0.99).No difference was seen in the median number of lymph nodes and lymph node ratio in N1 disease when compared by year(P = 0.17 and P = 0.96,respectively).CONCLUSION:There appears to be an overall underutilization of laparoscopy for DP.Centralization does not appear to be occurring.Survival and lymph node harvest have not changed.

Endoscopic sphincterotomy in the treatment of cholangiopancreatic diseases

AIM: To investigate the therapeutic effect of endoscopicsphincterotomy (EST) in the treatment of choledocholithiasis and stenosing papillitis.METHODS: A total of 1 026 patients undergoing EST during July 1983 to May 2003 at the institute were retrospectively analyzed. Chronic pancreatitis was diagnosed in 63 (6.1%),cholecystolithiasis and choledocholithiasis in 549 (53.5%),stones in residual biliary duct in 249 (24.3%), stenosing papillitis in 228 (22.2%). In patients with simple stenosing papillitis, most incisions were within 0.5-1 cm in length. As for patients with chronic pancreatitis simultaneously, selective pancreatic sphincterotomy was performed, and incision was within 0.5-0.8 cm in length. For stones less than 1 cm, incision was from 1 to 1.5 cm, and for those larger than 1 cm, incision ranged from 1.5 to 3 cm. For stones more than 2 cm in diameter, detritus basket rather than simple incision was chosen. RESULTS: Of the 798 patients with choledocholithiasis, 764 (93.5%) had successful stone clearance, 215 (94.3%)out of 228 cases of stenosing papillitis were cured totally, while 63 had chronic pancreatitis developed from stenosing papillitis, 57 (90.1%) had sound remission of symptoms, though membranous stenosis emerged in 13 of 57 which was treated with balloon dilatation. After the operation, only 21 cases (2.1%) had complications such as severe pancreatitis and incision bleeding. None of the patients died.CONCLUSION: EST is an ideal surgical management with mini-invasion in the treatment of choledocholithiasis and stenosing papillitis.

Neoadjuvant peptide receptor radionuclide therapy for an inoperable neuroendocrine pancreatic tumor

Pancreatic endocrine tumors are rare but are among the most common neuroendocrine neoplasms of the abdomen.At diagnosis many of them are already advanced and diff icult to treat.We report on an initially inoperable malignant pancreatic endocrine tumor in a 33-year-old woman,who received neoadjuvant peptide receptor radionuclide therapy(PRRT)as firstline treatment.This resulted in a signif icant downstaging of the tumor and allowed its subsequent complete surgical removal.Follow-up for eighteen months revealed a complete remission.This is the first report on neoadjuvant PRRT in a neuroendocrine neoplasm with subsequent successful complete resection.

Perioperative insulin therapy using a closed-loop artificial endocrine pancreas after hepatic resection

Postoperative hyperglycemia is common in critically ill patients, even in those without a prior history of diabetes mellitus. It is well known that hyperglycemia induced by surgical stress often results in dysregulation of liver metabolism and immune function, impairing postoperative recovery. Current evidence suggests that maintaining normoglycemia postoperatively improves surgical outcome and reduces the mortality and morbidity of critically ill patients. On the basis of these observations, several large randomized controlled studies were designed to evaluate the benefit of postoperative tight glycemic control with intensive insulin therapy. However, intensive insulin therapy carries the risk of hypoglycemia, which is linked to serious neurological events. Recently, we demonstrated that perioperative tight glycemic control in surgical patients could be achieved safely using a closed-loop glycemic control system and that this decreased both the incidence of infection at the site of the surgical incision, without the appearance of hypoglycemia, and actual hospital costs. Here, we review the benefits and requirements of perioperative intensive insulin therapy using a dosed-loop artificial endocrine pancreas system in hepatectomized patients. This novel intensive insulin therapy is safe and effectively improves surgical outcome after hepatic resection.

Pancreatic fistula after pancreaticoduodenectomy:A comparison between the two pancreaticojejunostomy methods for approximating the pancreatic parenchyma to the jejunal seromuscular layer:Interrupted vs continuous stitches

AIM： The purpose of this study is to find a better operative technique by comparing interrupted stitches with continuous stitches for the outer layer of the pancreaticojejunostomy, i.e. the stitches between the stump parenchyma of the pancreas and the jejunal seromuscular layer, and other risk factors for the incidence of pancreatic leakage.METHODS： During the period January 1997 to October 2004, 133 patients have undergone the end-to-side and duct-to-mucosa pancreaticojejunostomy reconstruction after pancreaticoduodenectomy with interrupted suture for outer layer of the pancreaticojejunostomy and 170 patients with a continuous suture at our institution by one surgeon.RESULTS： There were no significant differences between the two groups in the diagnosis, texture of the pancreas, use of octreotide and pathologic stage. Pancreatic fistula occurred in 14 patients （11%） among the interrupted suture cases and in 10 （6%） among the continuous suture cases （P = 0.102）. Major pancreatic leakage developed in three interrupted suture patients （2%） and zero continuous suture patients （P = 0.026）. In multivariate analysis, soft pancreatic consistency （odds ratio, 5.5; 95% confidence interval 2.3-13.1） and common bile duct cancer （odds ratio, 3.7; 95%CI 1.6-8.5） were＇predictive of pancreatic leakage.CONCLUSION： Pancreatic texture and pathology are the most important factors in determining the fate of pancreaticojejunal anastomosis and our continuous suture method was performed with significantly decreased occurrence of major pancreatic fistula. In conclusion, the continuous suture method is more feasible and safer in performing duct-to-mucosa pancreaticojejunostomy.

A new combined criterion to better predict malignant lesions in patients with pancreatic cystic neoplasms

Objective:Cystic lesions of the pancreas have been increasingly recognized.Some lesions exhibit benign behavior,while others have unequivocal malignant potential.Thus,accurate identification of malignancy in patients diagnosed with pancreatic cystic neoplasms(PCNs)remains a major challenge.The aim of this study was to define a combined criterion to better predict malignant lesions in patients with PCNs.Methods:We retrospectively analyzed 165 patients who underwent resection of PCNs from October 2011 to May 2017.The relationship among malignancy and serum carbohydrate antigen 19-9(CA19-9),preoperative neutrophil-to-lymphocyte ratio(NLR),and the presence of enhanced solid component on imaging was analyzed.Results:NLR before surgery in patients with malignant PCNs(2.81±2.14)was significantly higher than that in patients diagnosed with pancreatic neuroendocrine tumor(1.90±0.69,P=0.013)or healthy volunteers(1.40±0.48;P<0.001).Serum CA19-9≥39U/m L,NLR>1.976 and presence of enhanced solid component were independent predictors of PCN malignancy.A combined criterion meeting any two or more of the three elements including CA19-9≥39 U/m L,NLR>1.976,and presence of enhanced solid component on computed tomography imaging is an indicator with a high positive predictive value of 80.5%and a high negative predictive value of 87.9%,and thus,represents a highly accurate test(86.1%).Conclusions:The new combined criterion is an effective predictor of tumor malignancy in patients with PCNs.