Search

To introduce sub-adventitial divestment technique (SDT), a procedure to remove the tumor while preserving the artery during curative pancreatectomy. Peri-operative safety profile was also evaluated. In a single center consecutive series of pancreatectomy for pancreatic cancer, the outcome of patients who had pancreatectomy with SDT was compared to standard pancreatic surgery. From June 2014 to June 2016, 72 patients had pancreatectomy with SDT and 235 had standard surgery. Tumor stage was T4 in all 72 (100%) tumors removed using SDT compared to four (2%) with standard pancreatectomy (p

Pasireotide was recently suggested for the prevention of postoperative pancreatic fistula (POPF) after pancreatic surgery. However, its efficacy remains to be controversially dicussed. Therefore, we conducted a systematic review and meta-analysis to assess the efficacy of pasireotide for preventing POPF after pancreatic surgery. A systematic literature search was conducted in PubMed, Web of Science, and The Cochrane Library to identify clinical studies investigating the efficacy of pasireotide after pancreatic surgery. The identified studies were critically appraised, and meta-analyses were then performed. The study was performed in accordance with PRISMA guidelines and was registered at the PROSPERO study database (CRD42018112334). Four studies with a total of 919 patients were included: 418 with pasireotide treatment and 501 controls. Meta-analysis showed that pasireotide could reduce neither clinically relevant POPF rate (OR = 0.78; 95% CI, 0.49–1.24; P = 0.29) nor overall POPF rate (OR = 0.94; 95% CI, 0.60–1.48; P = 0.80) after pancreatic resections. There were no significant differences in delayed gastric emptying, mortality, and postoperative hospital stay after pancreatic surgery. However, pasireotide reduces readmission after pancreatic surgery (OR = 0.61; 95% CI, 0.44–0.85; P = 0.004). Subgroup analyses revealed that prophylactic use of pasireotide did not reduce the incidence of clinically relevant POPF after pancreaticoduodenectomy or distal pancreatectomy compared with the control. Based on the available evidence, use of pasireotide may not reduce clinically relevant POPF as well as it may not improve postoperative course substantially after pancreatic surgery. Further investigator-initiated high-quality trials are needed.

Background: Idiopathic chronic calcific pancreatitis is a rare entity. Early surgical intervention and a parenchyma sparing procedure should be advocated to prevent further decay of the pancreas and the occurrence of cancer. Case Presentations: Case 1: A 14-year-old boy presented with a 3-year history of right upper abdominal pain that has been aggravated in the last 2 months. Imaging revealed a dilated pancreatic duct of 6 mm with pancreatic duct stones in the head of pancreas. He underwent a Frey's procedure. Unfortunately, he was discharged with grade B pancreatic fistula. Case 2: A 12-year-old boy presented with a 1-year history of dull and recurring epigastric pain. Imaging studies showed multiple stones in a 12 mm dilated pancreatic duct. The patient underwent a modified Puestow procedure. Up to the 42th month follow-up, the patient had no pain complaints. Case 3: A 12-year-old boy with a 1-week history of a dull epigastric pain presented with with multiple stones in a 10 mm duct. He underwent a modified Puestow procedure and was discharged with alleviated pain. Conclusions: “Conservative” surgery allows satisfactory pancreatic duct drainage, reduced rehospitalizations, and longer pain relief than alternative endoscopic procedures.

Pancreatic cancer (PC) has posed a great health threat to a growing number of people all over the world. Detection of serum miRNAs, being sensitive, noninvasive, and easy to obtain, has a great potential of being a novel screening method for PC patients. In this study, we investigated miRNA expression levels in serum by qRT‐PCR. The study was divided into four phases: the screening, training, testing, and external validation stage. We firstly chose candidate miRNAs using Exiqon panels in the screening phase. Then, a total of 129 PC serum samples and 107 normal controls (NCs) were further analyzed in the following training and testing phases to identify differently expressed miRNAs. A cohort of 30 PC serum samples vs 30 NCs was used to confirm the diagnostic value of the identified miRNAs in the external validation phase. Moreover, miRNA expressions in additional 44 PC tumor tissue samples and the matched adjacent normal tissue samples as well as 32 pairs of serum‐derived exosomes samples were also further explored. As a result, we identified six significantly upregulated miRNAs in the serum of PC: let‐7b‐5p, miR‐192‐5p, miR‐19a‐3p, miR‐19b‐3p, miR‐223‐3p, and miR‐25‐3p. A six‐miRNA panel in serum was then established. The area under the receiver operating characteristic curves (AUC) for the panel was 0.910 for the combined training and testing phases, which showed higher diagnostic value than the individual miRNA. Prognostic value prediction using Cox's proportional hazards model and Kaplan‐Meier curves showed that increased serum miR‐19a‐3p was closely related to worse overall survival (OS). In addition, significant upregulation of miR‐192‐5p, miR‐19a‐3p, and miR‐19b‐3p was observed in both PC tissue and serum‐derived exosomes samples. In conclusion, we identified a six‐miRNA (let‐7b‐5p, miR‐192‐5p, miR‐19a‐3p, miR‐19b‐3p, miR‐223‐3p, and miR‐25‐3p) panel in the serum for PC early and noninvasive diagnosis.

Central pancreatectomy (CP) has been applied for treating benign and low-grade malignant tumors in pancreatic neck, but studies regarding CP for pancreatic ductal adenocarcinoma (PDAC) are quite limited. We aimed to investigate the role of central pancreatectomy in the treatment of PDAC in the neck of the pancreas. Patients who underwent CP at our hospital between 2009 and 2016 were identified. Patients treated by distal pancreatectomy (DP) were matched according to the tumor size, location, and staging. The surgical and survival outcomes were compared between the CP and DP groups. Nine patients had CP. Five (56%) had postoperative complications and three (33%) had clinically significant (grade B + C) fistula. No significant difference was found between the CP and DP groups for the rate of overall morbidity, pancreatic fistula, reoperation, and readmission. Tumor size was smaller in the CP group compared to the DP group. The mortality of both groups was zero. The median postoperative survival was similar between the two groups (20.4 months for CP vs 19.4 months for DP, P = 0.842). CP is safe for patients with small PDAC at the neck of the pancreas. Considering the good preservation of pancreatic endocrine and exocrine functions, CP could be considered as an alternative procedure for single small PDAC in pancreatic neck.

HHLA2 is a newly identified member of the B7 immune checkpoint family, but its function and crosstalk with immune cells is not fully understood. To gain insights into the HHLA2 expression profile and to determine the clinical significance and function of HHLA2 in pancreatic cancer, we performed immunohistochemistry (IHC) analyses on tissue microarrays (TMAs) of pancreatic ductal adenocarcinoma (PDAC, n = 92) with matched peritumoral tissues as well as in cohorts of precancerous lesions: pancreatic intraepithelial neoplasia (PanIN) and intraductal papillary mucinous neoplasm (IPMN). We found that HHLA2 was rarely detected in normal acinar, islet, and ductal cells but widely expressed from early pancreatic precancerous lesions to invasive PDAC. The overall HHLA2 positivity was 95% (19/20) in low grade PanIN and 70.73% (29/41) in IPMN. HHLA2 expression was detected in 77.17% (71/92) of the PDAC cases and was significantly associated with better prognosis in this cohort. Our findings suggest that HHLA2 may behave as a costimulatory ligand in pancreatic cancer, which differs from other B7 family members that are largely characterized as checkpoint inhibitors. Further investigation of the HHLA2 signaling pathway and its receptors is warranted by our data and may lead to novel therapeutic interventions.

ObjectiveThe aim of this study was to test the hypothesis that early oral feeding (EOF) is superior to early nasojejunal nutrition (ENN) after pylorus-preserving pancreaticoduodenectomy (PPPD) in terms of delayed gastric emptying (DGE).BackgroundDGE is a common complication after PPPD. Although EOF after PPPD is recommended by several international guidelines, there is no randomized trial to support this recommendation.MethodsFrom September 2016 to December 2017, a total of 120 patients undergoing PPPD were randomized into the ENN, EOF, or saline groups at a 1:1:1 ratio (40 patients in each group). The primary endpoint was the rate of clinically relevant DGE. Secondary endpoints included overall morbidity, postoperative pancreatic fistula, post-pancreatectomy hemorrhage, abdominal infection, length of hospital stay, reoperation rate, and in-hospital mortality.ResultsThe baseline characteristics and operative parameters were comparable between the groups. The incidence of clinically relevant DGE varied significantly among the three groups (ENN, 17.5%; EOF, 10.0%; saline, 32.5%; p =0.038). The saline group had a higher clinically relevant DGE rate than the EOF group (p = 0.014). The saline group also had greater overall morbidities than the ENN and EOF groups (p = 0.041 and p = 0.006, respectively). There were no significant differences in other surgical complication rates or postoperative hospital stay. No mortality was observed in any of the groups.ConclusionsNutritional support methods were not related to DGE after PPPD. EOF was feasible and safe after PPPD, and additional ENN should not be routinely administered to patients after PPPD.Clinical Trial RegistrationClinicalTrials.gov, identifier NCT03150615.

Background: Abdominal tuberculosis (TB) remains an issue as it masquerades as many malignant or benign abdominal conditions. Objective: To analyze the clinical and laboratory features of abdominal ...

Postoperative pancreatic fistula (POPF) is a major complication and main cause of mortality after pancreaticoduodenectomy (PD). Afferent loop decompression technique (ALDT) has theoretical feasibility to reduce the rate of POPF. The aim of this study is to determine whether ALDT is a protective factor for POPF. A total of 492 consecutive patients who underwent PD between January 2012 and December 2014 were identified from a prospective database. All data were extracted and events were judged based on medical records. Propensity score matching was conducted to balance several variables. Univariate and multivariate analyses were performed, respectively, to investigate the independent risk factors for pancreatic fistula. ALDT required a nasogastric tube with multiple side holes to be placed deep into the afferent jejunal limb. The rationale for this technique was to prevent pancreatic fistula by decreasing intraluminal pressure in the afferent jejunal loop by placement of the nasogastric tube and the application of continuous low-pressure suction after surgery. The total rate of POPF for the entire cohort was 30.7%, and ISGPS grade-A/B/C POPF rates were 18.1, 10.6 and 2.0%, respectively. In-hospital mortality was 1.6%. Among the 331 patients who received ALDT, 89 developed pancreatic leakage (26.9 vs. 38.5% for non-ALDT; P = 0.009) and eight developed biliary leakage (2.4 vs. 6.2% for non-ALDT; P = 0.035). Apart from ALDT, decreased preoperative ALT, soft pancreas, long operative time and tumour presence in the lower common bile duct (as opposed to the pancreas) were identified as other independent risk factors for POPF following multivariate logistic regression analysis. ALDT may reduce the incidence of POPF after PD.

Postoperative pancreatic fistula (POPF) is a major source of morbidity after pancreaticoduodenectomy (PD). The purpose of this retrospective study comparing 1-layer pancreaticojejunostomy (PJ) with 2-layer PJ after PD was to evaluate whether the 1-layer duct-to-mucosa PJ after PD can reduce the incidence of POPF. A total of 194 consecutive patients who underwent PD by one group of surgeons (led by Y.M.) from January 2011 to February 2014 were included in this study. Among those patients, 104 underwent 1-layer PJ (1-layer group), and 90 patients underwent 2-layer PJ (2-layer group). Preoperative clinicopathologic features, intraoperative parameters, and postoperative morbidity with a focus on POPF were compared between the 2 groups. The overall incidence of POPF was 19.6% (38 of 194 patients), and clinically relevant grade B and C POPF rates were 8.6% (16 of 194 patients) and 3.1% (6 of 194 patients), respectively. There were no differences in patient demographics and operation-related factors between the 2 groups. However, the incidence of POPF in the 1-layer group was significantly lower than in the 2-layer group [13.5% (14 of 104) of patients and 26.7% (24 of 90) of patients, respectively; P = 0.021]. The median postoperative hospital stay was also significantly shorter in the 1-layer group compared with the 2-layer group (13 versus 15 days, P = 0.035). One patient in the 2-layer group died of postoperative hemorrhage. One-layer duct-to-mucosa PJ is a simple and easy technique for pancreaticojejunal anastomosis after PD, and it can reduce the POPF rate in comparison with the 2-layer technique.

Background: Pancreatic solid pseudopapillary tumors (SPTs) are rare neoplasms with low-grade malignancy. The main treatment for them is surgical resection. However, some SPTs relapse after resection. The risk factors associated with the recurrences of resected SPTs remain controversial to date. We performed a systematic review and meta-analysis to identify the risk factors of the recurrences of pancreatic SPTs. Materials and Methods: We searched PubMed, EMBASE, and the Cochrane Library from their inception to December 2017. Studies that focused on the risk factors of postoperative relapses of pancreatic SPTs were enrolled. Combined ORs with 95% CIs were calculated to evaluate the effects of relevant factors investigated in eligible studies. Heterogeneity among combined results was assessed by Cochran's Q test and by the degree of inconsistency (I2). Statistical analyses were performed by Review Manager (version 5.3) using random effects models. Results: We included 10 studies, which enrolled 1091 patients. The pooled results suggested that patients with larger tumors (diameter > 5cm), lymphovascular invasion, lymph node metastasis, synchronous metastasis and positive margin were prone to suffer from the recurrences of SPTs. In addition, some factors like gender, location of tumors, perineural invasion, calcification and capsular invasion did not show any correlation with the relapses of resected SPTs. Conclusion: Factors including a larger tumor size (diameter > 5cm), lymphovascular invasion, lymph node metastasis, synchronous metastasis and positive margin may increase the risk of recurrences of resected pancreatic SPTs. All SPTs should be excised and patients with high-risk features should undergo a long-term follow-up.

Background Pathology is the gold standard for diagnosis of pancreatic cancer. Preoperative endoscopic ultrasound-guided biopsy is an expensive procedure that is not routine in developing countries, hence a cheap, reliable alternative is required. Aim To evaluate the effectiveness and safety of a new technique of intraoperative biopsy from pancreatic head mass. Methods Patients undergoing intraoperative transluminal core-biopsy (TLCB) for pancreatic head mass from January 2000 to June 2015 were included in this study. Following Kocher's maneuver, a biopsy was taken from the mass through the duodenum transluminally, using a commercial 16G automatic core-biopsy needle. Multiple tissue specimens were obtained for intraoperative frozen section examination. Depending on the pathological results, a decision was taken to either perform pancreaticoduodenectomy, duodenum-preserving pancreatic head resection, bypass surgery, or to just terminate the operation. The malignancy status of the lesion was confirmed by postoperative pathological examination and/or long-term follow-up of the patients. Results A total of 525 patients were included. Intraoperative pathological reports revealed 436 malignant cases and 89 cases without evidence of malignancy. The sensitivity, specificity, false positive rate, and false negative rate were 97.7%, 100%, 0%, and 2.3%, respectively. Complications occurred in 2 patients. Conclusion TLCB is a quick, safe, effective, and accurate method for intraoperative diagnosis method in patients with pancreatic head mass; it can provide reliable evidence for surgical decision-making.

Purpose: Glucagonoma is an extremely rare neuroendocrine tumor arising from pancreatic islet cells. Although patients with glucagonoma manifest multiple typical symptoms, early diagnosis remains difficult due to the scarcity of this disease. Methods: In this study, we retrospectively screened the database of the pancreas center of Nanjing Medical University. A total of six cases diagnosed as glucagonoma during the past 17 years were included. Their clinical characteristics and treatments were reviewed. Results: The six patients consisted of four females and two males. Their median age at diagnosis was 48.7 years (range 35–77). The time from onset of symptoms to diagnosis of glucagonoma ranged from 1.3 months to >10 years. Common symptoms included necrotizing migratory erythema shown in six of six patients (100%), diabetes mellitus in five of six patients (83%), stomatitis in four of six patients (67%), and weight loss in four of six patients (67%). Plasma glucagon levels were elevated in all patients (range 245.6–1132.2 pg/mL; n

Introduction Few studies have compared patency rates of the different methods of venous reconstruction (VR) during a pancreatectomy. This study aimed to evaluate the patency rates and the clinical impact of various reconstruction methods. Methods For the meta-analysis, databases were systematically searched to identify studies reporting the outcomes of patients who underwent PVR/SMVR. For the retrospective study, clinical data were retrospectively analyzed from patients who underwent a pancreatectomy and VR between Feb. 2009 and Oct. 2015. Patency was assessed by CT and/or ultrasound. Results For the meta-analysis, the long-term patency rates of the primary repair group and the autologous graft group were significantly higher than that of the synthetic graft group. For the retrospective study, the reconstruction consisted of primary repair in 62 cases (89.8%) and synthetic grafting in 7 cases (10.1%). Synthetic grafting was more likely to cause acute thrombosis compared with primary repair for PVR/SMVR (85.7% versus 16.7%). Acute thrombosis was associated with decreased median survival (12 versus 6 months) and increased hazard of death. Late thrombosis and stenosis were not associated with survival or serious clinical impact. Median survival for the primary repair group and the synthetic grafting group was 12 and 7 months, respectively. Conclusion Primary repair following PVR/SMVR is preferred and can be achieved in most situations. Stenosis should be noted when with risk factors (long segmental and tension), but it produced little clinical impact. Synthetic grafting was associated with a higher thrombosis rate. Acute thrombosis is associated with increased mortality and decreased survival.

The animal model of common bile duct ligation is very toxic; therefore, the aim of this study was to establish a new model of obstructive jaundice in rats with partial common bile duct obstruction. Male Sprague-Dawley rats were subjected to a sham operation or partial ligation of bile duct procedure. Serum biochemistry, liver histology, and expression of bile salt transporters were examined after surgery. Serum levels of aspartate aminotransferase, alkaline phosphatase, total bilirubin, and bile acids were significantly increased in the partial bile duct ligation group 3 days after surgery. However, these changes spontaneously normalized within 14 days after surgery in the partial bile duct ligation group compared with the sham group. Bile infarcts, ductular reaction, and abundant hepatocyte turnover were detected exclusively in the partial bile duct ligation group on postoperative day 3. However, these changes dramatically reversed 14 days after surgery. Bile salt transporter expression was significantly decreased at day 3 and gradually recovered in the following 2 weeks. In conclusion, the current rat model of obstructive cholestasis is reversible, representing the clinical characteristics of partial biliary obstruction, and may be used to investigate the effects of various therapeutic strategies on reversible acute cholestasis.

Background Patients with potentially resectable pancreatic ductal adenocarcinoma (PDAC) are frequently found to be unresectable on exploration due to small distant metastasis. This study was to investigate predictors of small distant metastasis in patients with potentially resectable PDAC. Methods Patients who underwent surgical exploration for potentially resectable PDAC from 2013 to 2014 were reviewed retrospectively and divided into two groups according to whether distant metastases were encountered on exploration. Then, univariate and multivariate logistic regression analyses were used to identify predictors of distant metastasis. A scoring system to predict distant metastasis of PDAC on exploration was constructed based on the regression coefficient of a multivariate logistic regression model. Results A total of 235 patients were included in this study. Mean age of the study population was 61.7 ± 10.4 years old. Upon exploration, distant metastases were found intraoperatively in 62 (26.4%) patients, while the remaining 173 were free of distant metastases. Multivariate logistic regression analysis identified that age ≤ 62 years old (p

Necrolytic migratory erythema (NME), diabetes mellitus and glucagon-secreting tumors form the hallmarks of glucagonoma syndrome, and represent the major clinical manifestations of glucagonoma. NME is usually presented as the initial complaint of patients. Due to the rare incidence of glucagonoma, its diagnosis is often delayed, which leads to its progression. Here, we report a case of NME with a typical skin rash, which was misdiagnosed and treated with corticosteroids for two years. Removal of the tumor in the pancreatic body led to the rapid relief of the symptoms. The aim of the present study is to demonstrate the typical characteristics of glucagonoma syndrome to clinicians in order to improve its diagnosis and treatment.

The outcomes of sporadic pancreatic ductal adenocarcinoma (PDAC) patients with germline mutations of BRCA1/BRCA2 remains unclear. The prognostic significance of BRCA1/BRCA2 mutations on survival is not well established.We performed targeted next-generation sequencing (NGS) to identify BRCA1/BRCA2 germline mutations in resected sporadic PDAC cases from 2000 to 2015. Germline BRCA mutation carriers were matched by age and tumor location to those with BRCA1/BRCA2 wild-type genes from our institutional database. Demographics, clinicopathologic features, overall survival (OS), and disease-free survival (DFS) were abstracted from medical records and compared between the 2 cohorts.Twenty-two patients with sporadic cancer and BRCA1 (n = 4) or BRCA2 (n = 18) germline mutations and 105 wild-type patients were identified for this case-control study. The BRCA1/BRCA2 mutations were associated with inferior median OS (20.2 vs 27.8 months, p = 0.034) and DFS (8.4 vs 16.7 months, p0.001) when compared with the matched wild-type controls. On multivariable analyses, a BRCA1/BRCA2 mutation (hazard ratio [HR] 2.10, p0.001), positive margin status (HR 1.72, p = 0.021), and lack of adjuvant therapy (HR 2.38, p0.001), were all independently associated with worse survival. Within the BRCA1/BRCA2 mutated group, having had platinum-based adjuvant chemotherapy (n = 10) was associated with better survival than alternative chemotherapy (n = 8) or no adjuvant therapy (n = 4) (31.0 vs 17.8 vs 9.3 months, respectively, p0.001).Carriers of BRCA1/BRCA2 mutation with sporadic PDAC had a worse survival after pancreatectomy than their BRCA wild-type counterparts. However, platinum-based chemotherapy regimens were associated with markedly improved survival in patients with BRCA1/BRCA2 mutations, with survival differences no longer appreciated with wild-type patients.

Postoperative pancreatic fistula (POPF) is a common complication following distal pancreatectomy (DP). However, the risk factors of this complication in patients after DP still remain controversial. The aim of our study is to estimate the association between potential risk factors and POPF. Relevant articles published up to June 21, 2016 were identified via PubMed, EMBASE, Web of Science, and The Cochrane Library. Studies that examined the risk factors of POPF following DP were enrolled. 20 articles (2070 patients) were finally included in this study. The pooled data suggested that patients with soft pancreas, higher Body Mass Index (BMI), blood transfusion, elevated intraoperative blood loss, and longer operative time had a decreased risk for POPF. However, age, gender, malignant pathology, types of stump closure, octreotide therapy, history of diabetes and chronic pancreatitis, splenectomy, multiorgan resection, main duct ligation, preoperative serum albumin levels, PGA felt wrapping, and extended lymphadenectomy could not be regarded as risk factors for POPF. Our analytic data demonstrated that pancreas texture, BMI, blood transfusion, intraoperative blood loss, and operative time were clinical predictor for POPF. This study may assist surgeons to screen patients with high risk of POPF and select appropriate treatment measures.

Lesson This case report can argue in favour of optimal surgical management for isolated metastases to the pancreas, especially in patients with low surgical risk.

Background: Cholecystectomy is carried out as one of the most extensive abdominal surgery. Patients with a long-term history of cholecystectomy may have an increased risk of pancreatic cancer. However, it’s uncertain whether prior cholecystectomy is associated with the outcome of patients with pancreatic cancer. This study was to demonstrate that prior cholecystectomy may lead to adverse perioperative outcomes in patients with pancreatic adenocarcinoma. Methods: Retrospective study comprising 755 consecutive patients with pathological diagnosis of pancreatic adenocarcinoma in Pancreas Center of the First Affiliated Hospital of Nanjing Medical University (January 2010 to December 2015) was conducted. Demographic details, surgery, tumor stage, pathology and complications were assessed. Patients were divided into NPC (no prior cholecystectomy) group and PC (prior cholecystectomy) group. PC group consist of three subgroups: RC (recent cholecystectomy), LTC (long term cholecystectomy), MTC (medium term cholecystectomy) group. Results: A total of 9.3% (70/755) of the patients underwent prior cholecystectomy, which was significantly more frequent than other operations. The rate is also abnormally higher than Chinese population (1.2%, 31/2,579). Five hundred and fifty-three patients with radical resection were selected. Compared to NPC group, PC group has more progressive tumor with relatively higher level of serum CA19-9 and possibly higher rate of lymph node metastasis. Further analysis showed that RC group had remarkably longer surgery time and more blood loss than NPC group. There was no significant difference of operative time and blood loss between LTC/MTC group and NPC group. Postoperatively, there was no statistical difference between LTC/MTC group and NPC group in complications as POPF (postoperative pancreatic fistula), DGE (delayed gastric emptying), hemorrhage and infection. There was also no notably difference in length of hospital stay these two groups. Conclusions: There is an abnormally high proportion of patients with cholecystectomy history in Chinese patients with pancreatic cancer. Patients with recent cholecystectomy history may have adverse perioperative outcome.

Middle-segment preserving pancreatectomy (MPP) is a novel procedure for treating multifocal lesions of the pancreas while preserving pancreatic function. However, long-term pancreatic function after this procedure remains unclear. The aims of this current study are to investigate short- and long-term outcomes, especially long-term pancreatic endocrine function, after MPP. From September 2011 to December 2015, 7 patients underwent MPP in our institution, and 5 cases with long-term outcomes were further analyzed in a retrospective manner. Percentage of tissue preservation was calculated using computed tomography volumetry. Serum insulin and C-peptide levels after oral glucose challenge were evaluated in 5 patients. Beta-cell secreting function including modified homeostasis model assessment of beta-cell function (HOMA2-beta), area under the curve (AUC) for C-peptide, and C-peptide index were evaluated and compared with those after pancreaticoduodenectomy (PD) and total pancreatectomy. Exocrine function was assessed based on questionnaires. Our case series included 3 women and 2 men, with median age of 50 (37–81) years. Four patients underwent pylorus-preserving PD together with distal pancreatectomy (DP), including 1 with spleen preserved. The remaining patient underwent Beger procedure and spleen-preserving DP. Median operation time and estimated intraoperative blood loss were 330 (250–615) min and 800 (400–5500) mL, respectively. Histological examination revealed 3 cases of metastatic lesion to the pancreas, 1 case of chronic pancreatitis, and 1 neuroendocrine tumor. Major postoperative complications included 3 cases of delayed gastric emptying and 2 cases of postoperative pancreatic fistula. Imaging studies showed that segments representing 18.2% to 39.5% of the pancreas with good blood supply had been preserved. With a median 35.0 months of follow-ups on pancreatic functions, only 1 patient developed new-onset diabetes mellitus of the 4 preoperatively euglycemic patients. Beta-cell function parameters in this group of patients were quite comparable to those after Whipple procedure, and seemed better than those after total pancreatectomy. No symptoms of hypoglycemia were identified in any patient, although half of the patients reported symptoms of exocrine insufficiency. In conclusion, MPP is a feasible and effective procedure for middle-segment sparing multicentric lesions in the pancreas, and patients exhibit satisfied endocrine function after surgery.

// Yun-Peng Peng 1,* , Chun-Hua Xi 1,* , Yi Zhu 1,2,* , Ling-Di Yin 1 , Ji-Shu Wei 1 , Jing-Jing Zhang 1,2 , Xin-Chun Liu 1 , Song Guo 1 , Yue Fu 1 and Yi Miao 1,2 1 Department of General Surgery, Pancreas Centre, First Affiliated Hospital, Nanjing Medical University, Nanjing, P.R.China 2 Institute of Tumor Biology, Jiangsu Province Academy of Clinical Medicine, Nanjing, P.R.China * These authors have contributed equally to this work Correspondence to: Yi Miao, email: // Keywords : CD226; CD96; TIGIT; NK cells; pancreatic cancer Received : February 01, 2016 Accepted : September 02, 2016 Published : September 10, 2016 Abstract The progression of pancreatic cancer (PC) is significantly associated with tumor immune escape, which may be associated with nature killer (NK) cell dysfunction. CD226, CD96, and TIGIT, which share the ligand CD155, play important roles in the regulation of NK cell function. The present study was conducted to investigate the roles of these molecules in NK cells from PC patients. Expression of these molecules on NK cells was detected from samples of 92 pancreatic cancer patients and 40 healthy controls. The expression of CD155 was also evaluated by immunohistochemistry in 88 pancreatic cancer tissues. The percentage of CD226 + and CD96 + NK cells was significantly lower in PC patients than in the healthy controls; however, the mean fluorescence intensity of CD226 and CD96 was not significantly different between the two groups. TIGIT expression on NK cells from PC patients was similar to that in the healthy controls. Additionally, the expression of CD226 was positively correlated with CD96. Further analysis demonstrated that the decrease in the percentage of CD226 + and CD96 + NK cells was associated with tumor histological grade and lymph node metastasis. Moreover, the CD155 levels in PC tissues were significantly higher than those in adjacent tissues. Our results suggest that a lower percentage of CD226 + and CD96 + NK cells may contribute to tumor immune escape in PC patients; moreover, the use of NK cells with high CD226 and CD96 expression to treat PC cells with high CD155 expression may have potential and should be explored in the future.

Hepatic infarcts or abscesses occur after hepatic artery interruption. We explored the mechanisms of hepatic deprivation-induced acute liver injury and determine whether partial portal vein arterialization attenuated this injury in rats. Male Sprague-Dawley rats underwent either complete hepatic arterial deprivation or partial portal vein arterialization, or both. Hepatic ischemia was evaluated using biochemical analysis, light microscopy, and transmission electron microscopy. Hepatic ATP levels, the expression of hypoxia- and inflammation-associated genes and proteins, and the expression of bile transporter genes were assessed. Complete dearterialization of the liver induced acute liver injury, as evidenced by the histological changes, significantly increased serum biochemical markers, decreased ATP content, increased expression of hypoxia- and inflammation-associated genes and proteins, and decreased expression of bile transporter genes. These detrimental changes were extenuated but not fully reversed by partial portal vein arterialization, which also attenuated ductular reaction and fibrosis in completely dearterialized rat livers. Collectively, complete hepatic deprivation causes severe liver injury, including bile infarcts and biloma formation. Partial portal vein arterialization seems to protect against acute ischemia-hypoxia-induced liver injury.

The epithelial-mesenchymal transition plays a crucial role in the progression of pancreatic cancer. The aim of this study was to examine the possible association between the epithelial-mesenchymal transition and cancer stem-like cells in pancreatic cancer. We used transforming growth factor β to induce an epithelial-mesenchymal transition. The proportion of pancreatic cancer stem-like cells was measured and sorted by flow cytometry. The expression of markers was measured by quantitative PCR and Western blot analysis. Cell cycle distribution was assessed by flow cytometry. We evaluated the migration and invasion activity by Transwell tests. The proportion of pancreatic cancer stem-like cells was significantly increased following transforming growth factor β treatment. Cells were sorted in culture, the cancer stem-like cells exhibited a higher degree of epithelial-mesenchymal transition and demonstrated upregulation of vimentin, a mesenchymal phenotypic marker, compared to the CD44(-)CD24(-) cells. Pancreatic cancer stem-like cells exhibited greater invasion and migration activity in vitro compared to the CD44(-)CD24(-) cells. These results suggested a direct link between epithelial-mesenchymal transition and cancer stem-like cells in pancreatic cancer.

Background/objectives We evaluated the diagnoses and surgical management of solid pseudopapillary tumors of the pancreas (SPTP) in a single center setting. Methods Demographic details, clinical presentations, imaging features, surgical strategies, and pathological findings of 97 consecutive patients who underwent surgery for pathologically confirmed SPTP between 2008 and 2016 were analyzed retrospectively. Results A total of 97 patients with SPTP accounted for 2.15% of total pancreatic surgeries (N = 4508). The mean age at diagnosis was 31.6 ± 13.92 years (range: 7–83 years), and males:females were 85:12. Chief complaints were abdominal pain or discomfort (n = 50). The mean transverse tumor diameter was 53.2 ± 2.76 mm (range: 14–170 mm). Tumors were localized to the pancreatic head (38.1%; 37/97), neck (12.4%; 12/97), body and tail (49.5%; 48/97). There were no significant differences in age of onset, presenting symptoms, and sites between males and females. A significant difference was found in the maximum diameter of SPTP across different age groups. Partial pancreatectomy was performed for patient with tumor ≥ 5 cm, and enucleation was performed when tumor was smaller than 5 cm. Pancreatic fistula was the main complication. Immunohistochemical markers for endocrine, exocrine and epithelial factors were used for a final diagnosis. During a median follow-up of 54 months (range: 7–121 months), 84 patients were alive without evidence of recurrence, and 13 patients were lost to follow-up. Conclusion SPTP surgical resection is a safe procedure with low morbidity and mortality, which is also effective even in the presence of invasiveness and metastases. Accurate initial diagnoses and follow up are essential.

The purpose of this study was to evaluate the diagnosis and surgical management of insulinomas in a single-center setting. Demographic details, clinical presentation, preoperative diagnosis, surgical strategy, and outcomes of 33 consecutive patients who underwent surgery for insulinoma were analyzed retrospectively. The median time from the first onset of symptoms to diagnosis was 24 months (range 3 days to 50 years). All cases presented with Whipple’s triad and had a fasting insulin to glucose ratio higher than 0.33. The preoperative detection rates of transabdominal ultrasonography, CT, MRI, and EUS were 22 % (2/9), 72 % (23/32), 75 % (9/12), and 80 % (4/5), respectively. Intraoperative manual palpation localized all cases. Enucleation was performed in 58 % of cases (19/33), partial pancreatic resection in 39 % (13/33), and enucleation plus partial resection in 3 % (1/33). Pancreatic fistula was the most common complication and occurred in 15 patients (45 %), including seven grade A, five grade B, and three grade C fistulas. There was no mortality. When compared with partial pancreatectomy, enucleation held a significant advantage in operative time and operative bleeding, with no significant differences in demographic data and postoperative complications. During a median follow-up period of 32 months, two patients were lost to follow-up and the remaining 31 patients were without evidence of recurrence. A fasting insulin release index larger than 0.3 is a reliable indicator for the diagnosis of insulinoma. Intraoperative palpation by an experienced surgeon can effectively complement an uncertain preoperative localization. Compared with partial pancreatic resection, enucleation showed significant benefit in terms of intraoperative blood loss and operation time.

Brunner's gland cysts are rare benign lesions that are mainly observed in the first and the second regions of the duodenum. Patients with Brunner's gland cyst demonstrate no specific symptoms. The present study reports the case of a patient with Brunner's gland cyst located in the duodenum in combination with a gastrointestinal stromal tumor (GIST) in the same region. To the best of our knowledge, the present study reports the first case of Brunner's gland cyst with GIST. A 58-year-old female patient was referred to Tianchang Hospital of Traditional Chinese Medicine (Tianchang, China) with a one-month history of upper abdominal discomfort, diarrhea and recurrent vomiting following the intake of food. Upper gastrointestinal endoscopy and a computed tomography scan revealed the presence of a round, cystic-like lesion with internal low density located within the duodenum. Pathological examination revealed that the cyst measured 0.3 cm in diameter and was consistent with a diagnosis of Brunner's gland cyst. Histopathology revealed that the cyst possessed characteristics of GIST. The patient underwent surgical exploration and tumor resection, and was discharged 2 weeks post-surgery. During the 12 month post-operative follow-up period, the outcome of the patient was good. This case study of Brunner's gland cyst combined with GIST enriches the present literature and promotes better understanding of the two diseases. Further investigation is required to explain the mechanism and association between the two rare diseases.