Unraveling the enigma:A comprehensive review of solid pseudopapillary tumor of the pancreas

Solid pseudopapillary tumor of the pancreas(SPTP)is a rare neoplasm predom-inantly observed in young females.Pathologically,CTNNB1 mutations,β-catenin nuclear accumulation,and subsequent Wnt-signaling pathway activation are the leading molecular features.Accurate preoperative diagnosis often relies on imaging techniques and endoscopic biopsies.Surgical resection remains the mainstay treatment.Risk models,such as the Fudan Prognostic Index,show promise as predictive tools for assessing the prognosis of SPTP.Establishing three types of metachronous liver metastasis can be beneficial in tailoring individu-alized treatment and follow-up strategies.Despite advancements,challenges persist in understanding its etiology,establishing standardized treatments for unresectable or metastatic diseases,and developing a widely recognized grading system.This comprehensive review aims to elucidate the enigma by consolidating current knowledge on the epidemiology,clinical presentation,pathology,molecular characteristics,diagnostic methods,treatment options,and prognostic factors.

Current status and progress of pancreatic cancer in China

Cancer is currently one of the most important public health problems in the world.Pancreatic cancer is a fatal disease with poor prognosis.As in most other countries,the health burden of pancreatic cancer in China is increasing,with annual mortality rates almost equal to incidence rates.The increasing trend of pancreatic cancer incidence is more significant in the rural areas than in the urban areas.Annual diagnoses and deaths of pancreatic cancer in China are now beyond the number of cases in the United States.GLOBOCAN 2012 estimates that cases in China account for 19.45%(65727/337872) of all newly diagnosed pancreatic cancer and 19.27%(63662/330391) of all deaths from pancreatic cancer worldwide.The population's growing socioeconomic status contributes to the rapid increase of China's proportional contribution to global rates.Here,we present an overview of control programs for pancreatic cancer in China focusing on prevention,early diagnosis and treatment.In addition,we describe key epidemiological,demographic,and socioeconomic differences between China and developed countries.Facts including no nationwide screening program for pancreatic cancer,delay in early detection resulting in a late stage at presentation,lack of awareness of pancreatic cancer in the Chinese population,and low investment compared with other cancer types by government have led to backwardness in China's pancreatic cancer diagnosis and treatment.Finally,we suggest measures to improve health outcomes of pancreatic cancer patients in China.

Utility of PET/CT in diagnosis, staging, assessment of resectability and metabolic response of pancreatic cancer

Pancreatic cancer is one of the most common gastrointestinal tumors, with its incidence staying at a high level in both the United States and China. However, the overall 5-year survival rate of pancreatic cancer is still extremely low. Surgery remains the only potential chance for long-term survival. Early diagnosis and precise staging are crucial to make proper clinical decision for surgery candidates. Despite advances in diagnostictechnology such as computed tomography(CT)and endoscopic ultrasound,diagnosis,staging and monitoring of the metabolic response remain a challenge for this devastating disease.Positron emission tomography/CT(PET/CT),a relatively novel modality,combines metabolic detection with anatomic information.It has been widely used in oncology and achieves good results in breast cancer,lung cancer and lymphoma.Its utilization in pancreatic cancer has also been widely accepted.However,the value of PET/CT in pancreatic disease is still controversial.Will PET/CT change the treatment strategy for potential surgery candidates?What kind of patients benefits most from this exam?In this review,we focus on the utility of PET/CT in diagnosis,staging,and assessment of resectability of pancreatic cancer.In addition,its ability to monitor metabolic response and recurrence after treatment will be emphasis of discussion.We hope to provide answers to the questions above,which clinicians care most about.

Preoperative evaluation of pancreatic ductal adenocarcinoma with synchronous liver metastasis: Diagnosis and assessment of unresectability

AIM To identify predictors for synchronous liver metastasis from resectable pancreatic ductal adenocarcinoma(PDAC) and assess unresectability of synchronous liver metastasis.METHODS Retrospective records of PDAC patients with synchronous liver metastasis who underwent simultaneous resections of primary PDAC and synchronous liver metastasis, or palliative surgical bypass, were collected from 2007 to 2015. A series of pre-operative clinical parameters, including tumor markers and inflammation-based indices, were analyzed by logistic regression to figure out predictive factors and assess unresectability of synchronous liver metastasis. Cox regression was used to identify prognostic factors in liver-metastasized PDAC patients after surgery, with intention to validate their conformance to the indications of simultaneous resections and palliative surgical bypass. Survival of patients from different groups were analyzed by the Kaplan-Meier method. Intra- and post-operative courses were compared, including complications. PDAC patients with no distant metastases who underwent curative resection served as the control group.RESULTS CA125 > 38 U/mL(OR = 12.397, 95%CI: 5.468-28.105, P < 0.001) and diabetes mellitus(OR = 3.343, 95%CI: 1.539-7.262, P = 0.002) independently predicted synchronous liver metastasis from resectable PDAC. CA125 > 62 U/mL(OR = 5.181, 95%CI: 1.612-16.665, P = 0.006) and age > 62 years(OR = 3.921, 95%CI: 1.217-12.632, P = 0.022) correlated with unresectability of synchronous liver metastasis, both of which also indicated a worse long-term outcome of liver-metastasized PDAC patients after surgery. After the simultaneous resections, patients with postoperatively elevated serum CA125 levels had shorter survival than those with post-operatively reduced serum CA125 levels(7.7 mo vs 16.3 mo, P = 0.013). The survival of liver-metastasized PDAC patients who underwent the simultaneous resections was similar to that of non-metastasized PDAC patients who underwent curative pancreatectomy alone(7.0 mo vs 16.9 mo, P < 0.001), with no higher rates of either pancreatic fistula(P = 0.072) or other complications(P = 0.230) and no greater impacts on length of hospital stay(P = 0.602) or post-operative diabetic control(P = 0.479).CONCLUSION The criterion set up by CA125 levels could facilitate careful diagnosis of synchronous liver metastases from PDAC, and prudent selection of appropriate patients for the simultaneous resections.

Is routine drainage necessary after pancreaticoduodenectomy?

With the development of imaging technology and surgical techniques, pancreatic resections to treat pancreatic tumors, ampulla tumors, and other pancreatic diseases have increased. Pancreaticoduodenectomy, one type of pancreatic resection, is a complex surgery with the loss of pancreatic integrity and various anastomoses. Complications after pancreaticoduodenectomy such as pancreatic fistulas and anastomosis leakage are common and significantly associated with patient outcomes. Pancreatic fistula is one of the most important postoperative complications; this condition can cause intraperitoneal hemorrhage, septic shock, or even death. An effective way has not yet been found to avoid the occurrence of pancreatic fistula. In most medical centers, the frequency of pancreatic fistula has remained between 9% and 13%. The early detection and routine drainage of anastomotic fistulas, pancreatic fistulas, bleeding, or other intra-abdominal fluid collections after pancreatic resections are considered as important and effective ways to reduce postoperative complications and the mortality rate. However, many recent studies have argued that routine drainage after abdominal operations, including pancreaticoduodenectomies, does not affect the incidence of postoperative complications. Although inserting drains after pancreatic resectionscontinues to be a routine procedure, its necessity remains controversial. This article reviews studies of the advantages and disadvantages of routine drainage after pancreaticoduodenectomy and discusses the necessity of this procedure.

Accuracy of routine multidetector computed tomography to identify arterial variants in patients scheduled for pancreaticoduodenectomy

AIM:To assess the efficacy of cross-sectional multidetector computed tomography(MDCT) imaging without arterialreconstruction to identify aberrant right hepatic artery(RHA) and celiac artery stenosis(CAS) in patients scheduled for pancreaticoduodenectomy.METHODS:Patients with peri-ampullary and pancreatic head tumors who underwent routine preoperative MDCT and subsequent computed tomography(CT) angiography(CTA),conventional angiography or pancreaticoduodenectomy between September 2007 and August 2013 were identified.Retrospective analysis of imaging data was undertaken using CTA,conventional angiographic and surgical findings as the reference standards.The accuracy,sensitivity,specificity,positive predictive value(PPV) and negative predictive value(NPV) of MDCT in evaluation of aberrant RHA and CAS were calculated.RESULTS:A group of 458 patients met the inclusion criteria of this study to detect aberrant RHA,and 181 cases were included to identify CAS.Fifty-four(11.8%) patients were confirmed to have aberrant RHA,while 12(6.6%) patients with CAS were demonstrated.MDCT yielded an accuracy of 98.5%,sensitivity of 96.3% and specificity of 98.8% in the detection of aberrant RHA.The sensitivity,specificity,PPV and NPV of MDCT for detecting CAS were 58.3%,98.2%,70% and 97.1%,respectively.CONCLUSION:Routine MDCT is recommended such that surgeons and radiologists be alerted to the importance of arterial variants on preoperative CT scans in patients scheduled for pancreaticoduodenectomy.

Implantation of Radioactive ^(125)I Seeds Improves the Prognosis of Locally Advanced Pancreatic Cancer Patients:A Retrospective Study

Locally advanced pancreatic cancer is associated with a very poor prognosis. This study was performed to evaluate whether patients with locally advanced pancreatic cancer benefit from 125 ^I seed implantation. This retrospective study included 224 patients with locally advanced pancreatic cancer, with 137 patients（61.2%） in the implantation（IP） group and 87（38.9%） in the non-implantation（NIP） group. The survival status, complications and objective curative effects were compared between the groups. The average operative time in the IP group was significantly longer than that in the NIP group（243±51 vs. 214±77 min）. The tumor response rates were 9.5% and 0 at the 2nd month after surgery in the IP and NIP groups, respectively（P〈0.05）. The IP group exhibited a trend toward pain relief at the 6th month after surgery. The global health status scores of the IP group were higher than those of the NIP group at the 3rd and 6th month after surgery. The median survival time in the IP group was significantly longer than that in the NIP group. In conclusion, patients with locally advanced pancreatic cancer can benefit from 125 I seed implantation in terms of local tumor control, survival time, pain relief and quality of life.

Clinical significance of variant hepatic artery in pancreatic resection:A comprehensive review

The anatomical structure of the pancreaticoduodenal region is complex and closely related to the surrounding vessels.A variant of the hepatic artery,which is not a rare finding during pancreatic surgery,is prone to intraoperative injury.Inadvertent injury to the hepatic artery may affect liver perfusion,resulting in necrosis,liver abscess,and even liver failure.The preoperative identification of hepatic artery variations,detailed planning of the surgical approach,careful intraoperative dissection,and proper management of the damaged artery are important for preventing hepatic hypoperfusion.Nevertheless,despite the potential risks,planned artery resection has become acceptable in carefully selected patients.Arterial reconstruction is sometimes essential to prevent postoperative ischemic complications and can be performed using various methods.The complexity of procedures such as pancreatectomy with en bloc celiac axis resection may be mitigated by the presence of an aberrant right hepatic artery or a common hepatic artery originating from the superior mesenteric artery.Here,we comprehensively reviewed the anatomical basis of hepatic artery variation,its incidence,and its effect on the surgical and oncological outcomes after pancreatic resection.In addition,we provide recommendations for the prevention and management of hepatic artery injury and liver hypoperfusion.Overall,the hepatic artery variant may not worsen surgical and oncological outcomes if it is accurately identified pre-operatively and appropriately managed intraoperatively.

Partial pancreatic tail preserving subtotal pancreatectomy forpancreatic cancer: Improving glycemic control and quality of lifewithout compromising oncological outcomes

BACKGROUND Total pancreatectomy (TP) is usually considered a therapeutic option forpancreatic cancer in which Whipple surgery and distal pancreatectomy areundesirable, but brittle diabetes and poor quality of life (QoL) remain majorconcerns. A subset of patients who underwent TP even died due to severehypoglycemia. For pancreatic cancer involving the pancreatic head and proximalbody but without invasion to the pancreatic tail, we performed partial pancreatictail preserving subtotal pancreatectomy (PPTP-SP) in selected patients, in order toimprove postoperative glycemic control and QoL without compromisingoncological outcomes.AIM To evaluate the efficacy of PPTP-SP for patients with pancreatic cancer.METHODS We retrospectively reviewed 56 patients with pancreatic ductal adenocarcinomawho underwent PPTP-SP (n = 18) or TP (n = 38) at our institution from May 2014to January 2019. Clinical outcomes were compared between the two groups, withan emphasis on oncological outcomes, postoperative glycemic control, and QoL.QoL was evaluated using the European Organization for Research and Treatmentof Cancer Quality of Life Questionnaire (EORTC QLQ-C30 and EORTC PAN26).All patients were followed until May 2019 or until death.RESULTS A total of 56 consecutive patients were enrolled in this study. Perioperativeoutcomes, recurrence-free survival, and overall survival were comparablebetween the two groups. No patients in the PPTP-SP group developed cancerrecurrence in the pancreatic tail stump or splenic hilum, or a clinical pancreaticfistula. Patients who underwent PPTP-SP had significantly better glycemiccontrol, based on their higher rate of insulin-independence (P = 0.014), lowerhemoglobin A1c (HbA1c) level (P = 0.046), lower daily insulin dosage (P < 0.001),and less frequent hypoglycemic episodes (P < 0.001). Global health was similar inthe two groups, but patients who underwent PPTP-SP had better functional status(P = 0.036), milder symptoms (P = 0.013), less severe diet restriction (P = 0.011),and higher confidence regarding future life (P = 0.035).CONCLUSION For pancreatic cancer involving the pancreatic head and proximal body, PPTP-SPachieves perioperative and oncological outcomes comparable to TP in selectedpatients while significantly improving long-term glycemic control and QoL.

Single-nucleotide polymorphisms based genetic risk score in the prediction of pancreatic cancer risk

BACKGROUND Disease-related single nucleotide polymorphisms(SNPs)based genetic risk score(GRS)has been proven to provide independent inherited risk other than family history in multiple cancer types.AIM To evaluate the potential of GRS in the prediction of pancreatic cancer risk.METHODS In this case-control study(254 cases and 1200 controls),we aimed to evaluate the association between GRS and pancreatic ductal adenocarcinoma(PDAC)risk in the Chinese population.The GRS was calculated based on the genotype information of 18 PDAC-related SNPs for each study subject(personal genotyping information of the SNPs)and was weighted by external odd ratios(ORs).RESULTS GRS was significantly different in cases and controls(1.96±3.84 in PDACs vs 1.09±0.94 in controls,P<0.0001).Logistic regression revealed GRS to be associated with PDAC risk[OR=1.23,95%confidence interval(CI):1.13-1.34,P<0.0001].GRS remained significantly associated with PDAC(OR=1.36,95%CI:1.06-1.74,P=0.015)after adjusting for age and sex.Further analysis revealed an association of increased risk for PDAC with higher GRS.Compared with low GRS(<1.0),subjects with high GRS(2.0)were 99%more likely to have PDAC(OR:1.99,95%CI:1.30-3.04,P=0.002).Participants with intermediate GRS(1.0-1.9)were 39%more likely to have PDAC(OR:1.39,95%CI:1.03-1.84,P=0.031).A positive trend was observed(P trend=0.0006).CONCLUSION GRS based on PDAC-associated SNPs could provide independent information on PDAC risk and may be used to predict a high risk PDAC population.

High Risk Factors of Pancreatic Carcinoma

Over the past decades, cancer has become one of the toughest challenges for health professionals. The epidemiologists are increasingly directing their research efforts on various malignant tumor worldwide. Of note, incidence of cancers is on the rise more quickly in developed countries. Indeed, great endeavors have to be made in the control of the life-threatening disease. As we know it, pancreatic cancer（PC） is a malignant disease with the worst prognosis. While little is known about the etiology of the PC and measures to prevent the condition, so far, a number of risk factors have been identified. Genetic factors, pre-malignant lesions, predisposing diseases and exogenous factors have been found to be linked to PC. Genetic susceptibility was observed in 10% of PC cases, including inherited PC syndromes and familial PC. However, in the remaining 90%, their PC might be caused by genetic factors in combination with environmental factors. Nonetheless, the exact mechanism of the two kinds of factors, endogenous and exogenous, working together to cause PC remains poorly understood. The fact that most pancreatic neoplasms are diagnosed at an incurable stage of the disease highlights the need to identify risk factors and to understand their contribution to carcinogenesis. This article reviews the high risk factors contributing to the development of PC, to provide information for clinicians and epidemiologists.

Surgical Selection for Late Pancreatic Head Carcinoma without Gastric Outlet Obstruction

The effects of different surgical procedures for late pancreatic head carcinoma without gas- tric outlet obstruction were explored in order to provide theoretical basis to select a suitable operation for these patients. The clinical data of 441 cases of late pancreatic head carcinoma without gastric outlet obstruction were retrospectively analyzed. All patients were divided into 4 groups based on different surgical procedures： group A （101 cases） subjected to Roux-en-Y cholecystojejunostomy; group B （133 cases） undergoing Roux-en-Y choledochojejunostomy; group C （83 cases） given Roux-en-Y chole- cystojejunostomy combined with gastrojejunostomy; group D （124 cases） receiving Roux-en-Y chole- dochojejunostomy combined with gastrojejunostomy. Therapeutic efficacy in each group was evaluated comparatively. Both groups B and D had a lower rate of postoperative obstructive jaundice than groups A and C separately （P〈0.05 for all）. The data of mean life span showed that both groups B and D had a lower survival rate than groups A and C separately （P〈0.05 for all）. The incidence of postoperative gas- tric outlet obstruction in groups A and B was higher than that in groups C and D separately （P〈0.05 for all）. The gastrojejunostomy had no impacts on the mean life span, and there was no statistically signifi- cant difference in complications, average hospital stay （days） and median survival among four groups （P〉0.05）. For the late pancreatic head carcinoma without gastric outlet obstruction, Roux-en-~ chole- dochojejunostomy is effective for the reduction of icteric index and the incidence of recurrent jaundice, also offers an opportunity for prolonged survival. Combined use of prophylactic Roux-en-Y gastrojeju- nostomy during surgical biliary drainage is safe for advanced pancreatic carcinoma with obstructive jaundice, which can decrease the incidence of postoperative gastric outlet obstruction, and has important implications for improving outcomes.

Is There Comparable Morbidity in Pylorus-preserving and Pylorus-resecting Pancreaticoduodenectomy? A Meta-analysis

Summary： Pancreaticoduodenectomy （PD） is the most effective treatment for patients with pancreatic head or periampullary lesions. Two major strategies exist： pylorus-preserving pancreaticoduodenectomy （PPPD） and pylorus-resecting pancreaticoduodenectomy （PRPD）. However, it is yet unclear regarding the morbidity after PPPD and PRPD. This study analyzed the morbidity after PPPD and PRPD to de- termine the optimal surgical treatment of masses in the pancreatic head or periampullary region. A sys- tematic search of databases identifying randomized controlled trials （RCTs） from the Cochrane Library, PubMed, EMBASE and Web of Science was performed. Outcome was compared by postoperative mor- bidity including overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding, biliary leakage, ascites and delayed gastric emptying （DGE） rate between PPPD and PRPD. The DGE rate in the PRPD subgroups （conventional PD [CPD] and subtotal stomach-preserving PD [SSPPD], respec- tively） was also analyzed. The results showed that 9 RCTs including 722 participants were included for meta-analysis. Among these RCTs, 7 manuscripts described PRPD as CPD, and 2 manuscripts described PRPD as SSPPD. There were no significant differences in the overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding, or biliary leakage between PPPD and PRPD. There was a lower rate of DGE with PRPD than that with PPPD （RR=2.15, P=0.03, 95% CI, 1.09-4.23）. Further subgroup analysis indicated a comparable DGE rate for the CPD but a lower DGE rate for the SSPPD group than the PPPD group. However, the result did not indicate any difference between CPD and SSPPD regarding the DGE rate （P=-0.92）. It is suggested that PPPD is comparable to PRPD in overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding and biliary leakage. The current data are not sufficient to draw a conclusion regarding which surgical procedure is associated with a lower postoperative DGE rate. Our conclusions were limited by the available data. Further evaluations of RCTs are needed.

Epidermoid cyst of intrapancreatic accessory spleen:A case report and literature review

Epidermoid cyst of intrapancreatic accessory spleen is exceedingly rare; only 30 new cases have been reported in the English literature over the last 30 years.An accurate preoperative diagnosis was made in almost none of them because of the lack of reliable preoperative diagnostic methods. In this report, we present a case diagnosed with fluorine-18 fluorodeoxyglucose positron emission tomography(FDG-PET). A 41-year-old female who had breast cancer was routinely followed up by measuring the concentration of tumor makers.An increasing level of serum carbohydrate antigen 19-9was detected and a cystic lesion located at the tail of pancreas was found by ultrasonography. A whole body fluorine-18 FDG positron emission tomography was performed because of a high suspicion for either a malignancy of the pancreas or a recurrence of breast cancer.No increased uptake of FDG was noted and therefore the cystic lesion was considered as pancreatic benign disease. Because pancreatic malignancy could not be entirely ruled out, distal pancreatectomy and splenectomy were performed. The final pathological diagnosiswas epidermoid cyst of intrapancreatic accessory spleen(ECIAS). The FDG-PET findings matched the histopathology. A literature review reveals that the common clinical manifestations of ECIAS include asymptomatic findings on clinical examination, an occasional increase in tumor makers on laboratory results and occurrence only in the pancreatic tail. It is often misdiagnosed due to its extreme rarity and lack of a specific radiographic sign. There is no evidence of malignancy in ECIAS. Open or laparoscopic spleen preserving distal pancreatectomy is the minimally invasive procedure that would provide the best surgical management for epidermoid cyst of intrapancreatic accessory spleen.

Discovery of a potent and highly selective inhibitor of SIRT6 against pancreatic cancer metastasis in vivo

Pancreatic cancer,one of the most aggressive malignancies,has no effective treatment due to the lack of targets and drugs related to tumour metastasis.SIRT6 can promote the migration of pancreatic cancer and could be a potential target for antimetastasis of pancreatic cancer.However,highly selective and potency SIRT6 inhibitor that can be used in vivo is yet to be discovered.Here,we developed a noveSIRT6 allosteric inhibitor,compound 11e,with maximal inhibitory potency and an IC_(50) value of 0.98±0.13μmol/L.Moreover,compound 11e exhibited significant selectivity against other histone deacetylases(HADC1-11 and SIRT1-3)at concentrations up to 100μmol/L.The allosteric site and the molecular mechanism of inhibition were extensively elucidated by cocrystal complex structure and dynamic structural analyses.Importantly,we confirmed the antimetastatic function of such inhibitors in four pancreatic cancer cell lines as well as in two mouse models of pancreatic cancer liver metastasis.To our knowledge,this is the first study to reveal the in vivo effects of SIRT6 inhibitors on liver metastatic pancreatic cancer.It not only provides a promising lead compound for subsequent inhibitor developmentargeting SIRT6 but also provides a potential approach to address the challenge of metastasis in pancreatic cancer.

Effects of different resuscitation fluid on severe acute pancreatitis

AIM: To compare effects of different resuscitation fluid on microcirculation, inflammation, intestinal barrier and clinical results in severe acute pancreatitis (SAP). METHODS: One hundred and twenty patients with SAP were enrolled at the Pancreatic Disease Institute between January 2007 and March 2010. The patients were randomly treated with normal saline (NS group), combination of normal saline and hydroxyethyl starch (HES) (SH group), combination of normal saline, hydroxyethyl starch and glutamine (SHG group) in resuscitation. The ratio of normal saline to HES in the SH and SHG groups was 3:1. The glutamine (20% glutamine dipeptide, 100 mL/d) was supplemented into the resuscitation liquid in the SHG group. Complications and outcomes including respiratory and abdominal infection, sepsis, abdominal hemorrhage, intra-abdominal hypertension, abdominal compartment syndrome (ACS), renal failure, acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS), operation intervention, length of intensive care unit stay, length of hospital stay, and mortality at 60 d were compared. Moreover, blood oxygen saturation (SpO 2 ), gastric intramucosal pH value (pHi), intra-abdominal pressure (IAP), inflammation cytokines, urine lactulose/mannitol (L/M) ratio, and serum endotoxin were investigated to evaluate the inflammatory reaction and gut barrier. RESULTS: Compared to the NS group, patients in the SH and SHG groups accessed the endpoint more quickly (3.9 ± 0.23 d and 4.1 ± 0.21 d vs 5.8 ± 0.25 d, P < 0.05) with less fluid volume (67.26 ± 28.53 mL/kg/d, 61.79 ± 27.61 mL/kg per day vs 85.23 ± 21.27 mL/kg per day, P < 0.05). Compared to the NS group, incidence of renal dysfunction, ARDS, MODS and ACS in the SH and SHG groups was obviously lower. Furthermore, incidence of respiratory and abdominal infection was significantly decreased in the SH and SHG groups, while no significant difference in sepsis was seen. Moreover, less operation time was needed in the SH and SHG group than the NS group, but the difference was not significant. The mortality did not differ significantly among these groups. Blood SpO 2 and gastric mucosal pHi in the SH and SHG groups increased more quickly than in the NS group, while IAP was significantly decreased in the SH and SHG group. Moreover, the serum tumor necrosis factor-α, interleukin-8 and C-reactive protein levels in the SH and SHG groups were obviously lower than in the NS group at each time point. Furthermore, urine L/M ratio and serum endotoxin were significantly lower in the SH group and further decreased in the SHG group.CONCLUSION: Results indicated that combination of normal saline, HES and glutamine are more efficient in resuscitation of SAP by relieving inflammation and sustaining the intestinal barrier.

Comprehensive treatments for hepatocellular carcinoma with tumor thrombus in major portal vein

AIM: To evaluate the efficacy of transcatheter arterial chemoembolisation(TACE) compared with surgical intervention and sorafenib for treatment of hepatocellular carcinoma(HCC) in patients with tumor thrombus extending to the main portal vein.METHODS: From 2009 to 2013, a total of 418 HCC patients with tumor thrombus extending to the main portal vein were enrolled in this study and divided into four groups. These groups underwent different treatments as follows: TACE(n = 307), surgical intervention(n = 54), sorafenib(n = 15) and palliativetreatment(n = 42). Overall survival rates were determined by Kaplan-Meier method, and differences between the groups were identified through log-rank analysis. Cox's proportional hazard model was used to identify the risk factors for survival.RESULTS: The mean survival periods for patients in the TACE, surgical intervention, sorafenib and palliative treatment groups were 10.39, 4.13, 5.54 and 2.82 mo, respectively. For the TACE group, the 3-, 6-, 12-and 24-mo survival rates were 94.1%, 85.9%, 51.5% and 0.0%, respectively. The corresponding rates were 60.3%, 22.2%, 0.0% and 0.0% for the surgical intervention group and 50.9%, 29.5%, 0.0% and 0.0% for the sorafenib group. Evidently, the results in the TACE group were significantly higher than those in the other groups(P < 0.0001). Furthermore, no significant difference among survival rates was observed between TACE with/without sorafenib(10.22 mo vs 10.52 mo, P = 0.615). No significant difference in survival rates was also found among the surgical intervention, sorafenib and palliative treatment groups(P > 0.05). These values significantly increased after TACE with/without sorafenib compared with other treatments(P < 0.05).CONCLUSION: For HCC patients with tumor thrombus extending to the main portal vein, TACE can yield a higher survival rate than surgical intervention or sorafenib treatment.

Prediction of malignancy and adverse outcome of solid pseudopapillary tumor of the pancreas

Since solid pseudopapillary tumor of the pancreas(SP-TP) was officially classified by the World Health Org-anization in 1996,SPTP has recently received special attention in the literature.Studies have shown that SPTP is a heterogeneous tumor,with a small percentage of patients harboring aggressive behaviors.However,cri-teria for malignancy grade in SPTP have not been well established.The prognosis of SPTP is generally good,with cases having a chance for long-term survival even with recurrence and/or metastasis after surgical resection.The current American Joint Committee on Cancer/Union for International Cancer Control tumor,node,metastasis staging system is not specific to SPTP.The lack of a pre-dictive staging classification that accurately describes the heterogeneity of this disease hinders meaningful research into optimal individualized therapy.Here we summarize and discuss the associated factors proposed for appraisal of the malignant potential and adverse outcome of SPTP.

Impact of postoperative glycemic control and nutritional status on clinical outcomes after total pancreatectomy

AIM To evaluate the impact of glycemic control and nutritional status after total pancreatectomy(TP) on complications, tumor recurrence and overall survival.METHODS Retrospective records of 52 patients with pancreatic tumors who underwent TP were collected from 2007 to 2015. A series of clinical parameters collected before and after surgery, and during the follow-up were evaluated. The associations of glycemic control and nutritional status with complications, tumor recurrence and long-term survival were determined. Risk factors for postoperative glycemic control and nutritional status were identified.RESULTS High early postoperative fasting blood glucose(FBG) levels(OR = 4.074, 95%CI: 1.188-13.965, P = 0.025) and low early postoperative prealbumin levels(OR = 3.816, 95%CI: 1.110-13.122, P = 0.034) were significantly associated with complications after TP. Postoperative Hb A1 c levels over 7%(HR = 2.655, 95%CI: 1.299-5.425, P = 0.007) were identified as one of the independent risk factors for tumor recurrence. Patients with postoperative Hb A1 c levels over 7% had much poorer overall survival than those with Hb A1 c levels less than 7%(9.3 mo vs 27.6 mo, HR = 3.212, 95%CI: 1.147-8.999, P = 0.026). Patients with long-term diabetes mellitus(HR = 15.019, 95%CI: 1.278-176.211, P= 0.031) and alcohol history(B = 1.985, SE = 0.860, P = 0.025) tended to have poor glycemic control and lower body mass index levels after TP, respectively.CONCLUSION At least 3 mo are required after TP to adapt to diabetes and recover nutritional status. Glycemic control appears to have more influence over nutritional status on longterm outcomes after TP. Improvement in glycemic control and nutritional status after TP is important to prevent early complications and tumor recurrence, and improve survival.

Hepatic microenvironment underlies fibrosis in chronic hepatitis B patients

BACKGROUND Chronic hepatitis B virus(HBV)infection is a leading cause of liver morbidity and mortality worldwide.Liver fibrosis resulting from viral infection-associated inflammation and direct liver damage plays an important role in disease management and prognostication.The mechanisms underlying the contribution of the liver microenvironment to fibrosis in HBV patients are not fully understood.There is an absence of effective clinical treatments for liver fibrosis progression;thus,establishing a suitable in vitro microenvironment in order to design novel therapeutics and identify molecular biomarkers to stratify patients is urgently required.AIM To examine a subset of pre-selected microenvironment factors of chronic HBV patients that may underlie fibrosis,with a focus on fibroblast activation.METHODS We examined the gene expression of key microenvironment factors in liver samples from patients with more advanced fibrosis compared with those with less severe fibrosis.We also used the human stellate cell line LX-2 in the in vitro study.Using different recombinant cytokines and growth factors or their combination,we studied how these factors interacted with LX-2 cells and pinpointed the crosstalk between the aforementioned factors and screened the most important factors.RESULTS Of the secreted factors examined,transforming growth factor(TGF)-β1,interleukin(IL)-1βand tumor necrosis factor(TNF)-αwere increased in patients with advanced fibrosis.We found that besides TGF-β1,IL-1βcan also induce a profibrotic cascade by stimulating the expression of connective tissue growth factor and platelet-derived growth factor(PDGF)in LX-2 cells.Furthermore,the proinflammatory response can be elicited in LX-2 cells following treatment with IL-1βand TNF-α,suggesting that stellate cells can respond to proinflammatory stimuli.By combining IL-1βand TGF-β1,we observed not only fibroblast activation as shown byαlpha-smooth muscle actin and PDGF induction,but also the inflammatory response as shown by increased expression of IL-1β.CONCLUSION Collectively,our data from HBV patients and in vitro studies demonstrate that the hepatic microenvironment plays an important role in mediating the crosstalk between profibrotic and proinflammatory responses and modulating fibrosis in chronic HBV patients.For the establishment of a suitable in vitro microenvironment for HBV-induced liver fibrosis,not only TGF-β1 but also IL-1βshould be considered as a necessary environmental factor.