The revised Atlanta criteria 2012 altered the classification,severity assessment and management of acute pancreatitis

BACKGROUND： The Atlanta criteria for acute pancreatitis （AP） has been revised recently. This study was to evaluate its practical value in classification of AP, the severity assessment and management. METHODS： The clinical features, severity classification, out- come and risk factors for mortality of 3212 AP patients who had been admitted in Ruijin Hospital from 2004 to 2011 were analyzed based on the revised Atlanta criteria （RAC） and the original Atlanta criteria （OAC）.

A study on arsenic trioxide inducing in vitro apoptosis of gastric cancer cell lines

INTRODUCTION Cell apoptosis,which involves the biologic regulation of the numbers and vital activity of cells,is an important metaboloc process in both normal cells and tumor cells.

Long-term results of small-diameter proximal splenorenal venous shunt:A retrospective study

AIM:To investigate recurrent variceal hemorrhage and long-term survival rates of patients treated with partial proximal splenorenal venous shunt.METHODS:Patients with variceal hemorrhage who were treated with small-diameter proximal splenorenal venous shunt in Ruijin Hospital between 1996 and 2009 were included in this study.Shunt diameter was determined before operation using Duplex Doppler ultrasonography.Peri-operative and long-term results in term of rehemorrhage,encephalopathy and mortality were followed up.RESULTS:Ninety-eight patients with Child A and B variceal hemorrhage received small-diameter proximal splenorenal venous shunt with a diameter of 7-10 mm.After operation,the patients’mean free portal pressure (P<0.01)and the flow rate of main portal vein(P< 0.01)decreased significantly compared with that before operation.The rates of rebleeding and mortality were 6.12%(6 cases)and 2.04%(2 cases),respectively.Ninety-one patients were followed up for 7 mo-14 years (median,48.57 mo).Long-term rates of rehemorrhage and encephalopathy were 4.40%(4 cases)and 3.30% (3 cases),respectively.Thirteen patients(14.29%)died mainly due to progressive hepatic dysfunction.Fiveand ten-year survival rates were 82.12%and 71.24%,respectively.CONCLUSION:Small-diameter proximal splenorenal venous shunt affords protection against variceal rehemorrhage with a low occurrence of encephalopathy in patients with normal liver function.

Clinical operational tolerance in liver transplantation:state-of-the-art perspective and future prospects

BACKGROUND:Liver transplantation is the definite treatment for end-stage liver diseases with satisfactory results.However,untoward effects of life-long immunosuppression prevent the development of alternative strategies to achieve better longterm outcome.Achieving clinical operational tolerance is the ultimate goal.DATA SOURCES:A PubMed and Google Scholar search using terms:"immune tolerance","liver transplantation","clinical trial","operational tolerance" and "immunosuppression withdrawal" was performed,and relevant articles published in English in the past decade were reviewed.Full-text publications relevant to the field were selected and relevant articles from reference lists were also included.Priority was given to those articles which are relevant to the review.RESULTS:Because of the inherent tolerogenic property,around 20%-30% of liver transplantation recipients develop spontaneous operational tolerance after immunosuppression withdrawal,and the percentage may be even higher in pediatric living donor liver transplantation recipients.Several natural killer and γδT cell related markers have been identified to be associated with the tolerant state in liver transplantation patients.Despite the progress,clinical operational tolerance is still rare in liver transplantation.Reprogramming the recipient immune system by creating chimerism and regulatory cell therapies is among newer promising means to achieve clinical liver transplantation tolerance in the future.CONCLUSION:Although clinical operational tolerance is still rare in liver transplantation recipients,ongoing basic research and collaborative clinical trials may help to decipher the mystery of transplantation tolerance and extend the potential benefits of drug withdrawal to an increasing number of patients in a more predictable fashion.

Emerging roles of the ribonucleotide reductase M2 in colorectal cancer and ultraviolet-induced DNA damage repair

AIM:To investigate the roles of the ribonucleotide reductase M2 (RRM2) subunit in colorectal cancer (CRC) and ultraviolet (UV)-induced DNA damage repair. METHODS:Immunohistochemical staining of tissue microarray was performed to detect the expression of RRM2. Seven CRC cell lines were cultured and three human colon cancer cell lines, i.e., HCT116, SW480 and SW620, were used. Reverse transcription polymerase chain reaction and Western blotting were performed to determine the mRNA and protein expression levels of RRM2, respectively. Cell proliferation assay, cell cycle analysis were performed. Cell apoptosis was evaluated by double staining with fluorescein isothiocyanate-conjugated Annexin Ⅴ and propidium iodide (PI) usingAnnexin Ⅴ/PI apoptosis kit. The motility and invasion of CRC cells were assessed by the Transwell chamber assay. Cells were irradiated with a 254 nm UV-C lamp to detect the UV sensitivity after RRM2 depletion. RESULTS:Immunohistochemical staining revealed elevated RRM2 levels in CRC tissues. RRM2 overexpression was positively correlated with invasion depth (P < 0.05), poorly differentiated type (P = 0.0051), and tumor node metastasis stage (P = 0.0015). The expression of RRM2 in HCT116 cells was downregulated after transfection, and HCT116 cell proliferation was obviously suppressed compared to control groups (P < 0.05). In the invasion test, the number of cells that passed through the chambers in the RRM2-siRNA group was 81 ± 3, which was lower than that in the negative control (289 ± 7) and blank control groups (301 ± 7.2). These differences were statistically significant (P < 0.01). Our data suggest that RRM2 overexpression may be associated with CRC progression. RRM2 silencing by siRNA may inhibit the hyperplasia and invasiveness of CRC cells, suggesting that RRM2 may play an important role in the infiltration and metastasis of CRC, which is a potential therapeutic strategy in CRC. In addition, RRM2 depletion increased UV sensitivity. CONCLUSION:These findings suggest that RRM2 may be a facilitating factor in colorectal tumorigenesis and UV-induced DNA damage repair.

Proinflammatory effects and molecular mechanisms of interleukin-17 in intestinal epithelial cell line HT-29

AIM:To evaluate the proinflammatory effects and molecular mechanisms of interleukin(IL)-17 in intestinal epithelial cell line HT-29.METHODS:HT-29 cells were cultured with IL-17,tumor necrosis factor(TNF)-α,or the combination of both IL-17 and TNF-α.Real-time PCR and Western blot were used to measure the gene expression levels of neutrophil chemokines CXCL1,CXCL2,CXCL5,CXCL6,IL-8and TH-17 cell chemokine CCL20,the phosphorylation levels of p38 and TNF-α,and the expression level of IL-8,after using the p38 inhibitor in HT-29 cells.The stable Act1 knockdown HT-29 cell line was established to further test the phosphorylation changes of p38,after using IL-17 and TNF-α.RESULTS:After HT-29 cells were cultured with IL-17and TNF-α,the expression levels of neutrophil chemokines(CXCL1,CXCL2,CXCL5,CXCL6,IL-8)and Th17chemokine(CCL20)significantly improved(24.96±2.53,28.47±2.87,38.08±2.72,33.47±2.41,31.7±2.38,44.37±2.73,respectively),and the differences were all statistically significant(P<0.01).Western blot results showed that IL-17 obviously enhanced the phosphorylation level of p38,which was induced by TNF-α.Compared with the control group,the expression level of IL-8 significantly declined(9.47±1.36 vs 3.06±0.67,P<0.01)when TH-29 cells were cultured with IL-17and TNF-α.p38 inhibition assay showed that the p38pathway played an essential role in the inflammatory response induced by IL-17.p38 phosphorylation levels could not be changed after using IL-17 and TNF-αin the stable Act1 knockdown HT-29 cell line.CONCLUSION:IL-17 significantly promoted the gene expression levels of TNF-α-induced neutrophil chemokines and Th17 cell chemokine.It is obvious that IL-17and TNF-αhave synergistic effects on p38.

Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery

AIM To investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.METHODS This is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy(RG), laparoscopic gastrectomy(LG), open gastrectomy(OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.RESULTS The present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients(RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery(P = 0.42) and stage of the disease(P = 0.16). Intraoperative blood loss was significantly lower in the LG(95.93 ± 119.22) and RG(117.91 ± 68.11) groups compared to the OG(127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG(27.78 ± 11.45), LG(24.58 ± 13.56) and OG(25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay(P < 0.0001). A similar complications rate was found(P = 0.13). The leakage rate was not different(P = 0.78) between groups.CONCLUSION Laparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.

P16 METHYLATION OF THE COLORECTAL CANCER AND ASSOCIATION WITH DUKES STAGES

Objective: To explore whether methylation of the CpG island in the promoter of the p16 tumor suppressor gene was associated with clinicopathological characteristics of the colorectal cancer patients. Methods: Methylation-specific PCR (MSP) was used to detect p16 methylation of the colorectal cancer patients. Results: In 58 sporadic colorectal cancer, 43.1% of the tumors had detectable p16 methylation. Dukes’ stage was associated with p16 methylation status. Dukes C, D patients (75%) were more likely to contain methylated p16 compared with Dukes A, B patients (13.3%). Conclusion: p16 methylation plays a role in the carcinogenesis of a subset of colorectal cancer. P16 methylation might be considered as a prognostic indicator.

STATUS OF SURGICAL TREATMENT OF RECTAL CANCER IN CHINA

The multimodality treatment methods of rectal cancer in China are presented. Extended radical excisions are used for Dukes’ B and C cases to reduce local recurrence. These include: high ligation with clearance of proximal lymph nodes at origin of inferior mesenteric artery, lateral pelvic lymphadenectomy, posterior or total pelvic exenterations in selected cases; but controversy exists. Radical sphincter-saving resections are advocated to improve the quality of life. Prerequisites of sphincter-saving resection are adequate resection of bowel and mesentery distal to the lesion, depending on the macroscopic type of lesion and degree of differentiation. The decisive factor in the choice of type of operation is the length of rectal stump above levator ani after resection. Bacon’s pull through resection was modified by preservation of levator ani and dentate margin, much better functional results were obtained postoperatively. Transanal full thickness local excision is advocated for small, protuberant, mobile, well differentiated lesions below the peritoneal reflection. Pre- or postoperative adjuvant radiation therapy is sometimes used for Dukes’ B and C cases. Adjuvant 5-Fu chemotherapy is usually used intraoperatively (intraluminal) or postoperatively (intravenous). The superiority of preoperative intrarectal 5-Fu emulsionover the conventional intravenous route has been demonstrated by experimental and clinical studies, which showed much higher and lasting concentration of 5-Fu in the rectal wall tissues and mesenteric lymph nodes, and a much lower concentration of 5-Fu in bone marrow after intrarectal administration. Several surgical groups employed varying techniques of sphincteric reconstruction of perineal colostomy after abdominoperineal excision, utilizing the gracilis or gluteus maximus sling, or intussusception of the colonic stump; with favorable late results in reported cases. However, controversy exists, so strict appropriate case selection is emphasized to avoid unnecessary sacrifice of the normal anus.

THE PRESENT STATUS OF SURGICAL TREATMENT OF GASTRIC CANCER IN CHINA

Gastric cancer remains one of the leading malignancies in China. The history of modern surgical treatment of gastric cancer could be dated back to the early fifties with an overall 5-year survival rate of around 10%. Remarkable progress has been achieved ever since in terms of operability, resectability and 5-year survival rate which ranges now from 30% to over 50% after radical resection. In regard to problems and future perspective, apart from the effort which should be redoubled in increasing the detection rate of EGC, the need to popularize the new international TNM staging system, to carry out in-depth studies on the biological behavior of gastric cancers and the role of the spleen in the evolution of gastric cancer, and to include new potential adjuvant measures in the therapeutic regimen of AGC are emphasized.

A COMPARATIVE STUDY OF DNA FLOW CYTOMETRY AND MICROSPECTROPHOTOMETRY IN GASTRIC CARCINOMAS

Flow cytometric (FCM) and microspectrophotometric (MSP) measurements of cell nuclear DNA content were made in 53 fresh gastric carcinoma specimens and in 30 gastric mucosal specimens with chronic gastritis. DNA aneuploidy was found in 32/53 (60%) of gastric carcinomas, and appeared more frequently in wellor moderately differentiated tubular adenocarcinomas (90%) than in undifferentiated and mucousa cell carcinomas (23.6%) (P【0.001). No aneuploidy was found in chronic gastritis samples, but their proliferative cell fractions were higher than in normal control gastric mucosa samples (P【0.01). A comparison was made between FCM and MSP analyses of DNA content in 29 cases of gastric carcinoma, a high correlation rate (r=0.90) was found. The advantages and limitations of both methods are discussed, they may be used in combination for more precise cytochemical analysis.

Investigation of the relationship between DNA-dependent protein kinase and lymphatic metastasis in colorectal cancer

Objective: To investigate DNA-dependent protein kinase (DNA-PK) expression,and its relationship with lymphat-ic metastasis in colorectal cancer. Methods: Tumor tissues from 60 patients,divided into two groups according to lymphatic metastasis,were immunohistochemically stained to detect the DNA-PK expression including Ku70,Ku80 and PKcs proteins. Results: Positivity of both Ku70 and Ku80 in colorectal cancer was negatively correlated with lymphatic metastasis with an r value of -0.57 and -0.38,respectively. Similar correlation was found between Ku expression,especially Ku70,and long-term survival. PKcs,however,displayed no significant correlation. Statistical analysis failed to detect any correlation between DNA-PK expression,and clinical characteristics,such as age,sex,tumor location,tumor thickness and distant metastasis (P>0.05). Conclusion: DNA-PK expression,especially Ku70 expression,is negatively correlated with lymphatic metastasis,and the survival of patients with colorectal cancer. Ku70 expression may be a potential indicator for the preoperative evaluation,and prognosis in colorectal cancer.

METABOLISM PATTERN OF FECAL BILE ACIDS IN PATIENTS WITH LARGE BOWEL CANCER

The feca! bite acids were extracted from 21 patients with large bowel (colonic and rectal) cancer and 21 controls, and the bile acid composition and concentration were measured by gas chromatography. The total bile acid concentration and concentration of individual bile acids were not statistically different between colonic and rectal cancer. Bat the concentration and the percentage composition of secondary bile acids (deoxycholic and lithocholic acids) were significantly higher than that in controls. However the percentage composition of primary bile acids (cholic and chenocholic acids) were significantly lower than that in controls. The results suggest that incidence of large bowel cancer is closely related to the metabolism of fecal bile acids, and the etiology of colonic and rectal cancers may be the same.

EFFECTS OF INFLAMMATORY CELLS IN COLD AND WARM ISCHEMIA-REPERFUSION INJURY OF THE GRAFTED LIVER

Objective To investigate whether the impairment of grafted livers after transplantation was induced by the same inflammatory cells both in cold and warm ischemia. Methods Male SD rats were divided into two groups at random,24 donor livers in each group were stored in Ringers solution at 4℃ for 120min or 240min of transplantation for blood sample and tissue specimen collection. Results Along with the prolongation of cold and warm ischemia time,the serum ALT,AST and LDH level increased gradually after transplantation.Under light microscopy,some hepatocytes presented necrosis after 3h and 6h of transplantation in cold ischemia,and neutrophilic infiltration in sinusoids were evident.Also,a large number of hepatocytes were necrotic 3h or 6h after transplantation in warm ischemia from NHBDs,and lymphocytic infiltration was evident in the sinusoids.The findings in electron microscopy was as the same as those of light microscopy,and the cells which infiltrated the sinusoids in warm ischemia were identified as T lymphocytes. Conclusion The impairment of grafted livers after transplantation appeared to be induced by two different kinds of inflammatory cells in cold and warm ischemia,that is,neutrophils mediated the cold ischemia-reperfusion,and T lymphocytes mediated the warm ischemia-reperfusion from NHBDs,but these findings are to be comfirmed in further investigations.

Surgical management in biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury

AIM: To discuss the surgical method and skill of biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury. METHODS: From November 2005 to December 2006, eight patients with biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury were admitted to our hospital. Their clinical data were analyzed retrospectively. RESULTS: Bile duct injury was caused by cholecys- tectomy in the eight cases, including seven cases with laparoscopic cholecystectomy and one with mini- incision choleystectomy. According to the classification of Strasberg, type E1 injury was found in one patient, type E2 injury in three, type E3 injury in two and type E4 injury in two patients. Both of the type E4 injury patients also had a vascular lesion of the hepatic artery. Six patients received Roux-en-Y hepaticojejunostomy for the second time, and one of them who had type E4 injury with the right hepatic artery disruption received right hepatectomy afterward. One patient who had type E4 injury with the proper hepatic artery lesion underwent liver transplantation, and the remaining one with type E3 injury received external biliary drainage. All the patients recovered fairly well postoperatively. CONCLUSION: Roux-en-Y hepaticojejunostomy is still the main approach for such failed surgical cases with bile duct injury. Special attention should be paid to concomitant vascular injury in these cases. The optimal timing and meticulous and excellent skills are essential to the success in this surgery.

Clinical mycophenolic acid monitoring in liver transplant recipients

In liver transplantation, the efficacy of mycophenolate mofetil(MMF) has been confirmed in clinical trials and studies. However, therapeutic drug monitoring for mycophenolic acid(MPA) has not been fully accepted in liver transplantation as no long-term prospective study of concentration controlled vs fixed-dose prescribing of MMF has been done. This review addressed MPA measurement, pharmacokinetic variability and reasons of this variation, exposure related to acute rejection and MMF-associated side effects in liver transplant recipients. Limited sampling strategies to predict MPA area under the concentration-time curve have also been described, and the value of clinical use needs to be investigated in future. The published data suggested that a fixed-dosage MMF regimen might not be suitable and monitoring of MPA exposure seems helpful in various clinical settings of liver transplantation.

Self-management and self-efficacy status in liver recipients

BACKGROUND： Liver transplantation （LT） is a viable treatment for patients with end-stage chronic liver diseases. The main aim of LT is to prolong life and improve life quality. However, although survival after LT continues to improve, some aspects of recipient＇s health-related quality of life such as self-man- agement and self-efficacy have been largely ignored.

A powerful HUPAN on a pan-genome study: significance and perspectives

Recently,a report explaining the construction of a Human Pangenome ANalysis(HUPAN)system attracted wide attention in the biomedicine community.The original article was published in Genome Biology,a leading international journal in genomics1.Many researchers,particularly those conducting basic medical research.

Double-balloon enteroscopy reliably directs surgical intervention for patients with small intestinal bleeding

AIM: To evaluate preoperative double-balloon enteroscopy for determining bleeding lesions of small intestine, thus directing selective surgical intervention. METHODS: We retrospectively reviewed 56 patients who underwent double-balloon enteroscopy to localize intestinal bleeding prior to surgical intervention, and compared enteroscopic findings with those of intraoperation to determine the accuracy of enteroscopy in identifying and localizing the sites of small intestinal bleeding. RESULTS: Double-balloon enteroscopy was performed in all 56 patients in a 30-mo period. A possible site of blood loss was identified in 54 (96%) patients. Enteroscopy provided accurate localization of the bleeding in 53 (95%) of 56 patients, but failed to disclose the cause of bleeding in 4 (7%). There was one case with negative intraoperative finding (2%). Resection of the affected bowel was carried out except one patient who experienced rebleeding after operation. Gastrointestinal stromal tumor (GIST) was most frequently diagnosed (55%). CONCLUSION: Double-balloon enteroscopy is a safe, reliable modality for determining bleeding lesion of small intestine. This technique can be used to direct selective surgical intervention.

Surgical experience in splitting donor liver into left lateral and right extended lobes

AIM： To outline the surgical experience with donor liver splitting in split liver transplantation.METHODS： From March 1 to September 1 in 2004, 10 donor livers were split ex situ into a left lateral lobe （segments Ⅱ and Ⅲ） and a right extended lobe （segments Ⅰ, Ⅳ-Ⅷ） in Medical School of Hannover, and thereafter split liver transplantation was performed successfully in 29 cases. The average age, weight and ICU slaying period of the donors were 32.7 years （25-52 years）, 64.5 kg（45-75 kg） and 2.4 d （2-8 d） respectively.RESULTS： The average weight of the whole graft and the left lateral lobe was 2 322.6 g （956-2 665 g） and 282.8 g （298-373 g） respectively, and the average ratio of left lateral lobe to the whole graft was 0.225 （0.278-0.274）.The average graft to recipient weight ratio （GRWR） of the left lateral lobe and the right extended lobe reached 2.44% （2.22-5.42%） and 2.73% （2.32-2.30%） respectively.On average it took approximately 205 min （85-235 rain）to split the donor liver. Five donor organs showed anatomic variation including the left hepatic vein variation in two cases, the left hepatic artery variation in two cases and the bile duct variation in one case.CONCLUSION： Split liver transplantation has become a mature surgical technique to expand the donor pool with promising results. In the process of graft splitting, close attention needs to be paid to potential anatomic variations,especially to variations of the left hepatic vein, the left hepatic artery, and the bile duct.