Prognostic Value of ALP and LDH in Periampullary Carcinoma Patients Undergoing Surgery

Objective:Conversion of normal cells to cancer cells is often accompanied by abnormal synthesis of serum enzymes.Both alkaline phosphatase(ALP)and lactate dehydrogenase(LDH)have been reported to have prognostic value in a variety of malignancies.The aim of this study was to investigate the effect of preoperative serum ALP and LDH levels on the prognosis of patients with periampullary carcinoma who underwent pancreatoduodenectomy(PD).

Discussion on gemcitabine combined with targeted drugs in the treatment of pancreatic cancer

Pancreatic cancer is a malignant tumor with poor prognosis.The treatment of pancreatic cancer depends on the tumor stage and type,and includes local treatment(surgery,radiotherapy and ablation intervention)and systemic therapy(chemotherapy,targeted therapy and immunotherapy).We read with great interest the review“Effective combinations of anti-cancer and targeted drugs for pancreatic cancer treatment”published on World J Gastroenterol and intended to share some of our perspectives in pancreatic cancer treatment.This review presents the therapeutic effects of the combination of gemcitabine and targeted drugs,which gives us a deeper insight into the combination treatments for pancreatic cancer.

Intraductal papillary mucinous neoplasm originating from a jejunal heterotopic pancreas:A case report

BACKGROUND Intraductal papillary mucinous neoplasm(IPMN)is a rare pancreatic tumor and has the potential to become malignant.Surgery is the most effective treatment at present,but there is no consensus on the site of resection.Heterotopic pancreas occurs in the gastrointestinal tract,especially the stomach and duodenum but is asymptomatic and rare.We report a case of ectopic pancreas with IPMN located in the jejunum.CASE SUMMARY A 56-year-old male patient suffered from severe pain,nausea and vomiting due to a traffic accident and sought emergency treatment at our hospital.Contrast-enhanced computed tomography of the whole abdomen suggested splenic congestion,which was considered to be splenic rupture.Emergency laparotomy was performed,and the ruptured spleen was removed during the operation.Unexpectedly,a cauliflower-like mass of about 2.5 cm×2.5 cm in size was incidentally found about 80 cm from the ligament of Treitz during the operation.A partial small bowel resection was performed,and postoperative pathology confirmed the small bowel mass as heterotopic pancreas with low-grade IPMN.CONCLUSION Ectopic pancreas occurs in the jejunum and is pathologically confirmed as IPMN after surgical resection.

Risk factors and managements of hemorrhage associated with pancreatic fistula after pancreaticoduodenectomy

BACKGROUND: Post-pancreaticoduodenectomy pancreatic fistula associated hemorrhage(PPFH) is one of the leading lethal complications. Our study was to analyze the risk factors and managements of hemorrhage associated with pancreatic fistula after pancreaticoduodenectomy, and to evaluate treatment options.METHOD: We analyzed 445 patients who underwent pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy and evaluated the relevance between clinical data and PPFH.RESULTS: The incidence of postoperative pancreatic fistula(POPF) was 27.42%(122/445), and the incidence of PPFH was 4.49%(20/445). Among the 20 patients with PPFH, 7died and 13 were cured. Interventional angiographic therapy was performed for 10 patients and 5 were successfully treated. Relaparotomy was performed for 5 patients and 2 were successfully cured. Univariate logistic regression analysis indicated that several risk factors were related to PPFH: the nature of tumor(carcinoid/low-grade or high-grade malignancy), preoperative day 1 serum prealbumin, preoperative day 1 total bilirubin(TBIL), operative time, blood loss in the operation, operative method(vascular resection and revascularization), postoperative day 3 TBIL, biliary fistula, and the grade of POPF. The multivariate stepwise logistic regression analysis demonstrated that the nature of tumor and the grade of POPF were independently risk factors of PPFH. Receiver operating characteristic curve indicated that preoperative day 1 serum prealbumin level <173 mg/L and postoperative day 3 TBIL level ≥168 μmol/L were the risk factors of PPFH.CONCLUSIONS: The risk of PPFH was found to be increased with high potential malignancy and high grade of POPF. Angiography-embolization is one of the major and effective therapies for PPFH. Extraluminal-intraluminal PPFH is more serious and needs more aggressive treatments.

Pancreaticoduodenectomy for borderline resectable pancreatic head cancer with a modified artery-first approach technique

BACKGROUND: The treatment of borderline resectable pancreatic head cancer(BRPHC) is still controversial and challenging. The artery-first approaches are described to be the important options for the early determination. Whether these approaches can achieve an increase R0 rate, better bleeding control and increasing long-term survival for BRPHC are still controversial. We compared a previously reported technique, a modified artery-first approach(MAFA), with conventional techniques for the surgical treatment of BRPHC.METHODS: A total of 117 patients with BRPHC undergone pancreaticoduodenectomy(PD) from January 2013 to June 2015 were included. They were divided into an MAFA group(n=78) and a conventional-technique group(n=39). Background characteristics, operative data and complications were compared between the two groups.RESULTS: Mean operation time was significantly shorter in the MAFA group than that in the conventional-technique group(313 vs 384 min; P=0.014); mean volume of intraoperative blood loss was significantly lower in the MAFA group than that in the conventional-technique group(534 vs 756 m L; P=0.043); and mean rate of venous resection was significantly higher in the conventional-technique group than that in the MAFA group(61.5% vs 35.9%; P=0.014). Pathologic data, early mortality and morbidity were not different significantly between the two groups.CONCLUSIONS: MAFA is safe, simple, less time-consuming, less intraoperative blood loss and less venous resection, and therefore, may become a standard surgical approach to PD for BRPHC with the superior mesenteric vein-portal vein involvement but without superior mesenteric artery invasion.

Inhibition of Metastatic Progression of SSTR2 Gene Transfection Mediated by Adenovirus in Human Pancreatic Carcinoma Cells

The inhibition of metastatic progression of Somatostatin receptor type 2 (SSTR2) gene transfection mediated by adenovirus in human pancreatic carcinoma cells and the mechanisms involved in this effect were studied. The full-length human SSTR2 cDNA was introduced into the pancreatic cancer cell line BXPC-3 by adenovirus-mediated transfection. Stable expression of mRNAs and protein of SSTR2 was detected by RT-PCR and Western-blot. The Matrigel-coated Transwell was used to detect the migratory and invasive ability of SSTR2-expressing cells, Adv-GFP control cells and mock control cells. Furthermore, the expression of matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of metalloproteinase-2 (TIMP-2) was detected by RT-PCR in these cells. The stable expression of SSTR2 was detected in BXPC-3 transfected by Adv-GFP-SSTR2. A dramatic decrease of BXPC-3 expressing sst2 cells migrating through a Matrigel-coated filter was observed, as compared with Adv-GFP control and mock control cells (P<0.01). Moreover, the expression of MMP-2 mRNA was significantly reduced in the SSTR2-expressing cells and conversely the expression of TIMP-2 mRNA was significantly increased in the SSTR2-expressing cells when compared with the Adv-GFP control and mock control (P<0.01). The expression of reintroduced human SSTR2 gene in BXPC-3 cells by Adv-GFP-SSTR2 had the anti-migratory and anti-invasive effects, and the mechanisms involved in this effect may be due to the down-regulated expression of MMP-2 and up-regulated expression of TIMP-2.

“Total Arterial Devascularization First” Technique for Resection of Pancreatic Head Cancer during Pancreaticoduodenectomy

Integrated resection of the pancreatic head is the most difficult step in radical pancreaticoduodenectomy(RPD) in patients with the portal vein(PV) and superior mesenteric vein(SMV) invasion or oppression by the tumor. This study introduced a new idea and skill named the "total arterial devascularization first"(TADF) technique and its applications in RPD. Three arterial blood supplies of pancreatic head were obstructed before dissection of veins. The critical steps included exposure of the anterior surface of the abdominal aorta(AA) by completely transecting neural and connective tissue between superior mesenteric artery(SMA) and pancreatic mesounsinate, and transection of the mesounsinate from the origin of SMA to the root of the celiac trunk. From January 2012 through May 2013, a total of 58 patients with PV/SMV invasion or oppression underwent RPD using this technique.The median operative time was 5.1 h(ranging 4.5–8.1 h). The median intraoperative blood loss was 450mL(ranging 200–900 mL). No intraoperative and postoperative bleeding of pancreatic head region occurred. Among the 58 patients, 21 were subjected to vessel lateral wall angiectomy or angiorrhaphy, and 10 to angiectomy and end-to-end anastomosis. The incidence of postoperative bleeding, postoperative pancreatic fistula and biliary fistula was 5.2%, 6.8%, and 1.7%, respectively. No patients died 3 months after operation. The TADF technique is a new method for intricate RPD and could improve the security of surgery and reduce intraoperative bleeding, which is expected to become standardized surgical approach for RPD.

A new approach for Roux-en-Y reconstruction after pancreaticoduodenectomy

BACKGROUND: Postoperative pancreatic fistula remains the most common complication of pancreaticoduodenectomy (PD) and is potentially lethal. It contributes significantly to prolonged hospitalization and mortality. In this study, we introduced a new technical approach, a modified Roux-en-Y reconstruction and evaluated its safety and feasibility.METHODS: We retrospectively reviewed the patients who had undergone PD with the modified Roux-en-Y reconstructive technique for periampullary malignancies from January 2011 to June 2012. The data on complications, hospital stay and outcomes after the modified Roux-en-Y reconstruction were analyzed.RESULTS: The reconstruction was performed in 171 patients, of whom 92 received pancreaticogastrostomy and 79 received pancreaticojejunostomy. The median duration of surgery was 4.0 hours (range 3.1-6.9) in all patients, and the median blood loss was 530 m L (range 200-2000). Sixty-nine patients were subjected to transfusions, with a median transfusion volume of 430 m L (range 200-1400). The median hospital stay of the patients was 14 days (range 11-38). Their operative mortality was zero and overall morbidity was 18.1% (31 patients). Only four patients (2.3%) developed pancreatic fistulas (grade A fistulas in two patients and grade B in two patients); no patients developed grade C fistula. None of the patients developed bile reflux gastritis.CONCLUSIONS: The modified Roux-en-Y reconstruction, which isolates biliary anastomosis from pancreatic, gastric or jejunalanastomosis, is a safe, reliable, and favorable technique. But it needs further investigation in randomized controlled trials.

Huge primary dedifferentiated pancreatic liposarcoma mimicking carcinosarcoma in a young female: A case report

BACKGROUND Pancreatic liposarcoma is a rare tumor. According to a literature review, the patient described in this study is the seventh case of pancreatic liposarcoma reported in the English literature and the third case of dedifferentiated liposarcoma. Furthermore, this case had the largest primary tumor volume, and a primary pancreatic liposarcoma was diagnosed based on sufficient evidence. CASE SUMMARY We here report a rare case of a 28-year-old female with a huge dedifferentiated liposarcoma in the pancreatic tail. In June 2015, the patient underwent distal pancreatectomy with splenectomy. During the operation, a huge liposarcoma of approximately 28.0 cm × 19.0 cm × 8.0 cm was found, which had a yellow and white fish-like incisal surface. Based on both pathology and MDM2 gene amplification, the tumor was diagnosed as a dedifferentiated liposarcoma. The patient was treated with surgery but declined postoperative chemotherapy. She was well at the 26-mo follow-up, and no relapse was observed. CONCLUSION Pancreatic liposarcoma has a low incidence. Chemotherapy should be included in the treatment regimens. Complete resection is the only effective treatment.

Ileocecal intussusception caused by two different tumors - which is the culprit lesion? A case report

BACKGROUND Ileocecal intussusception caused by two different tumors is rare,according to a literature review.We describe a case of a male patient with a cauliflower-like mass in the middle of the transverse colon observed by colonoscopy before surgery.It was considered to be intussusception caused by colon cancer.However,a substantial lipomatous mass was seen in the distal end of the intussusception by computed tomography before surgery,which posed a challenge in the preoperative diagnosis.CASE SUMMARY We report a 72-year-old male patient with intussusception.The patient underwent right hemicolectomy and cholecystectomy in our hospital on April 29,2019.During operation,the ileum was inserted into the ascending colon by about 15 cm,and a tumor with a diameter of approximately 3.0 cm was observed in the distal part of the intestine.An atypical liposarcoma/highly differentiated liposarcoma in the adipose tissue was suspected in the postoperative pathology,and a lipoma was diagnosed after MDM2 gene testing.A 4.0 cm×5.0 cm polypoid mass was seen immediately adjacent to the mass,and the postoperative pathology report suggested a high-level tubular adenoma.The patient was eventually cured and discharged with an uneventful follow-up.CONCLUSION Intussusception caused by two different types of masses is extremely rare.At present,surgery is the best treatment once intussusception is diagnosed.

Perioperative risk factors for delayed gastric emptying after pancreaticoduodenectomy:a meta-analysis of the complications

Objective:To evaluate the correlation between the incidence of delayed gastric emptying(DGE)in pancreaticoduodenectomy(PD)and the perioperative possible risk factors.Methods:We searched PubMed,Embase,Cochrane Library,and Medline for studies describing complications related to PD from 2018 to 2022.Statistical analysis was performed using Stata/SE16.0 software.Results:In 6 retrospective studies,1 systematic review,and 1 randomized controlled trial(RCT)experiment,12,419 patients(2174 and 10,245 patients,respectively,in DGE and no delayed gastric emptying[NDGE]groups).The preoperative American Society of Anesthesiologists(ASA)score between DGE and NDGE groups(log odds ratio[OR]=0.23,95%credible interval[CI]:0.11-0.35,P<.01),operation time(mean diff.=21.87,95%CI:15.96-27.78,P<.01),estimated intraoperative blood loss(EIBL;mean diff.=70.67,95%CI:17.75-123.58,P<.05),postoperative pancreatic fistula(POPF)(log OR=0.85,95%CI:0.24-1.46,P<.05)were statistically significant.No significant differences in preoperative body mass index(BMI),preoperative biliary drain-age,and pancreatic texture were observed(P>.05).Conclusion:The incidence of DGE is significantly correlated with the operation time,preoperative ASA score,POPF,and EIBL,which suggests that the surgeon should thoroughly evaluate the patient through adequate preoperative examination before the operation.Finally,standardized practice and perfect technology are undoubtedly necessary to reduce complications.

Liver metastasis of pancreatic cancer: the new choice at the crossroads

In recent years,the incidence of pancreatic cancer has increased markedly both in China and internationally.For patients with pancreatic cancer,surgical resection remains the only effective method of obtaining a cure and long-term survival,although only few patients can expect this benefit.

Pancreatic head cancer with gastrointestinal bleeding as the initial manifestation:a case report and literature review

Gastrointestinal bleeding(GIB)as the initial symptom is rare in patients with pancreatic cancer,which is prone to misdiagnosis and should be paid attention to by clinicians.Here,we present a patient with pancreatic head cancer whose first symptom was only severe upper gastrointestinal bleeding,which initially led to misdiagnosis.However,subsequent imaging revealed a mass in the pancreatic head which was considered a malignant tumor.After surgical resection,the pathology confirmed that the mass in the pancreatic head was pancreatic ductal adenocarcinoma,and the duodenal bulb’s full thickness was infiltrated.A literature review found that pancreatic cancer can present gastrointestinal bleeding by invading the digestive tract and blood vessels,left-sided portal hypertension(LSPH),digestive tract metastasis,and canceration of ectopic pancreatic tissue in the digestive tract.For these cases,clinicians should utilize multidisciplinary diagnosis and treatment based on digestive endoscopy,imaging,interventional therapy,and surgery to control bleeding,identify etiology,and remove tumors.

Consensus of clinical diagnosis and treatment for non-functional pancreatic neuroendocrine neoplasms with diameter<2 cm

In clinical practice,pancreatic neuroendocrine neoplasms(pNENs)with a diameter smaller than 2 cm are commonly referred to as small pNENs.Due to their generally favorable biological characteristics,the diagnosis and treatment of small pNENs differ from other pNENs and are somewhat controversial.In response to this,the Chinese Pancreatic Surgery Association,Chinese Society of Surgery,Chinese Medical Association have developed a consensus on the diagnosis and treatment of small pNENs,which is based on evidence-based medicine and expert opinions.This consensus covers various topics,including concepts,disease assessment,treatment selection,follow-up,and other relevant aspects.

Guidelines for the diagnosis and treatment of acute pancreatitis in China (2021)

Acute pancreatitis(AP)is a common acute abdominal condition of the digestive system.In recent years,treatment concepts,methods,and strategies for the diagnosis of AP have advanced,and this has played an important role in promoting the standardization of AP diagnosis and treatment and improving the treatment quality of AP patients.On the basis of previous guidelines and expert consensus,this guideline adopts an evidence-based,problem-based expression;synthesizes important clinical research data at home and abroad in the most recent 5 years;and forms 29 recommendations through multidisciplinary expert discussion,including diagnosis,treatment,and follow-up.It is expected to provide evidence support for the treatment of AP in the clinical setting in China.

The Chinese guidelines for the diagnosis and treatment of pancreatic neuroendocrine neoplasms(2020)

Pancreatic neuroendocrine neoplasms(pNENs)are highly heterogeneous,and the management of pNENs patients can be intractable.To address this challenge,an expert committee was established on behalf of the Chinese Pancreatic Surgery Association,which consisted of surgical oncologists,gastroenterologists,medical oncologists,endocrinologists,radiologists,pathologists,and nuclear medicine specialists.By reviewing the important issues regarding the diagnosis and treatment of pNENs,the committee concluded evidence-based statements and recommendations in this article,in order to further improve the management of pNENs patients in China.

Guidelines for the diagnosis and treatment of pancreatic cancer in China (2021)

The incidence of pancreatic cancer has been rising worldwide,and its clinical diagnosis and treatment remain a great challenge.To present the update and improvements in the clinical diagnosis and treatment of pancreatic cancer in recent years,Chinese Pancreatic Association,the Chinese Society of Surgery,Chinese Medical Association revised the Guidelines for the Diagnosis and Treatment of Pancreatic Cancer in China(2014)after reviewing evidence-based and problem-oriented literature published during 2015-2021,mainly focusing on highlight issues regarding diagnosis and surgical treatment of pancreatic cancer,conversion strategies for locally advanced pancreatic cancer,treatment of pancreatic cancer with oligo metastasis,adjuvant and neoadjuvant therapy,standardized processing of surgical specimens and evaluation of surgical margin status,systemic treatment for unresectable pancreatic cancer,genetic testing,as well as postoperative follow up of patients with pancreatic cancer.Forty recommendation items were finally proposed based on the above issues,and the quality of evidence and strength of recommendations were graded using the Grades of Recommendation,Assessment,Development,and Evaluation system.This guideline aims to standardize the clinical diagnosis and therapy,especially surgical treatment of pancreatic cancer in China,and further improve the prognosis of patients with pancreatic cancer.