[The clinical value of radical resection of retroperitoneal lipo-lymphatic layer for pancreatic head cancer]

Objective: To investigate the clinical value of the novel approach,radical resection of the retroperitoneal lipo-lymphatic layer (RRRLLL),in the surgical treatment of resectable pancreatic head cancer. Methods: Between June 2020 and June 2022,a total of 221 patients with pancreatic head cancer underwent surgical treatment using the RRRLLL approach(RRRLLL group),while 107 patients received traditional surgical treatment(traditional group) in five high-volume pancreatic centers in China. Data from surgical technique and clinical perioperative outcomes,including lymph node harvested,surgical time,and complications,were analyzed. The RRRLLL group consisted of 144 males and 77 females with an age of (67.5±9.0) years(range:41.3 to 81.1 years). The traditional group included 71 males and 36 females,with an age of (66.3±8.1) years(range:45.1 to 79.2 years). Statistical analysis was performed using the K-S test,Z test,or χ2 test. Results: Pancreaticoduodenectomy was performed successfully in all patients,achieving R0 resection. RRRLLL group surgery required mobilization of retroperitoneal adipose and lymphatic tissues starting from the right edge of the inferior vena cava and extending to the left side,up to the superior mesenteric artery,down to the inferior mesenteric artery,and left to the left side of the aorta,including the perineural and lymphatic tissues around the superior mesenteric artery and the sheath of the mesenteric artery. However,the traditional group did not include the areas mentioned above in the scope of clearance. There were no statistically significant differences between the RRRLLL group and the traditional group in terms of age,sex,tumor size,T stage,and vascular invasion (all P>0.05). However,the number of lymph nodes harvested in the RRRLLL group was significantly higher at 28.7±9.0 (range: 18 to 39) compared to 18.2±8.0 (range: 12 to 21) in the traditional group (Z=-10.691,P<0.05). There were no statistically significant differences in the number of positive lymph nodes,N staging,and postoperative complications between the two groups. Conclusion: The RRRLLL approach improved lymph node dissection compared to the traditional approach,potentially leading to reduced recurrence rates.

[The value and controversy of laparoscopic pancreaticoduodenectomy in the treatment of pancreatic cancer]

Pancreatic cancer was considered to be one of the contraindications of laparoscopic pancreaticoduodenectomy, but a large number of studies have shown that laparoscopic pancreaticoduodenectomy is safe and feasible for surgeons who have passed the learning curve in high-volume hospitals.Laparoscopic pancreaticoduodenectomy can provide high-resolution intraoperative exploration and unique operative perspective,which can help to reduce intraoperative and postoperative complications,dissect lymph nodes more thoroughly and reduce intraoperative metastasis of tumors,so as to promote the development of postoperative adjuvant therapy and improve patients' quality of life.However,due to the long learning curve and unclear survival outcome, the application of laparoscopic pancreaticoduodenectomy in patients with pancreatic cancer is still controversial.This article summarizes the existing literature and the experience of the author's team,exploring the value and controversy of laparoscopic pancreaticoduodenectomy in the treatment of pancreatic cancer.Further,suggestions are put forward on how to improve the laparoscopic pancreaticoduodenectomy in China.

[Comparative study of short-term efficacy,effectiveness and safety at different stages of the laparoscopic pancreaticoduodenectomy learning curve]

Objective: To compare short-term efficacy,effectiveness and safety of laparoscopic pancreaticoduodenectomy(LPD) learning curve at different stages and at the same time with open pancreaticoduodenectomy(OPD). Methods: Clinical data of 488 patients who underwent pancreaticoduodenectomy at Department of Biliary-Pancreatic Surgery,Affiliated Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology from July 2014 to December 2016 were collected. There were 40 cases at the groping stage of LPD surgery(100 cases at the same time of OPD),64 cases at the stable stage (89 cases at the same time of OPD),and 118 cases at the mature stage(77 cases at the same time of OPD).The clinical data of LPD and OPD in the same period were compared and analyzed by χ² test,t test and U test,respectively. Results: There was no significant difference in preoperative indicators between the two groups at the three stages(all P>0.05). In terms of intraoperative blood volume of the LPD group was significantly lower than that of the OPD group at three stages(M(Q_R))(111.1(150.0)ml(range:0 to 700 ml) vs. 393.9(400.0)ml(range:0 to 3 000 ml),120.8(115.0)ml(range:0 to 1 000 ml) vs. 442.9(450.0)ml(range:0 to 2 000 ml) and 150.0(200.0)ml(range:10 to 1 500 ml) vs. 364.3(400.0)ml(range:0 to 1 500 ml))(all P<0.05). And in terms of operation time of the LPD group was significantly higher than that of the OPD group at the groping stage((461.1±123.9)min(range:220 to 690 minutes) vs. (385.9±113.9)minutes(range:150 to 655 minutes))(P<0.05),and there was no significant difference between the LPD group and the OPD group at the stable and mature stage(P>0.05). The incidence of B+C level pancreatic fistula of the LPD group was higher than that of the OPD group at groping stage(17.5% vs. 3.0%)(P<0.05). There was no significant difference between the LPD group and the OPD group at the stable and mature stage(P>0.05). The incidence of postoperative rebleeding(27.5%),bile leakage(20.0%) and abdominal infection(20.0%) of the LPD group was higher than those of the OPD group(11.0%(11/100),5.0%(5/100) and 7.0%(7/100)) at groping stage. There were no significant differences between the LPD group and the OPD group at the stable and mature stage(P>0.05). There were no significant differences of incidence gastrointestinal leakage,hepatic failure,renal failure,cardiac failure,pulmonary infection and 30-day death between the LPD group and the OPD group(all P>0.05). The incidence rate of gastroplegia in the LPD group was lower than that in the OPD group at the stable and mature stage(26.5%(17/64) vs. 44.9%(40/89) and 24.5%(29/118) vs. 38.9%(30/77))(all P<0.05),there was no significant difference between the LPD group and the OPD group at the groping stage(P>0.05). In terms of other incidence of complications,there were no significant differences between the LPD group and the OPD group at three stages(all P>0.05). There were no significant differences of positive margin rate of pancreas,bile duct,retroperitoneum,vascular channel,uncinate process and rate of R0 resection between the LPD group and the OPD group at three stages(all P>0.05). In terms of numbers of lymph nodes,there was no significant difference between the LPD group and the OPD group at three stages(all P>0.05).Postoperative hospital stay of the LPD group was shorter than that of the OPD group at the stable stage((14.8±6.9)days(range:10 to 38 days) vs. (17.0±9.0)days(range:4 to 56 days)) and the mature stage((13.0±7.4)days(range:3 to 57 days) vs. (15.8±6.7)days(range:6 to 69 days)(all P<0.05). Conclusion: with the stable and mature learning curve of LPD surgery,compared with traditional OPD surgery,it has the characteristics of less intraoperative bleeding,shorter postoperative hospitalization,lower incidence of delay gastric empty,safe and effective.

[A multicenter clinical analysis of short-term efficacy of laparoscopic radical resection of hilar cholangiocarcinoma]

Objective: To investigate the feasibility and safety of laparoscopic radical resection of hilar cholangiocarcinoma at multiple centers in China. Methods: Between December 2015 and August 2019, the clinical data of 143 patients who underwent LRHC in Affiliated Hospital of North Sichuan Medical College, Second Hospital of Hebei Medical University, Affiliated Hospital of Xuzhou Medical University, Affiliated Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Hunan Provincial People's Hospital, the First Hospital Affiliated to Army Medical University, Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, West China Hospital of Sichuan University, Nanfang Hospital of Southern Medical University and the First Affiliated Hospital of Chongqing Medical University were collected prospectively. There were 92 males and 51 females with age of (64±11) years (range: 53 to 72 years). Bismuth type: type I, 38 cases (26.6%), type Ⅱ, 19 cases (13.3%), type Ⅲa, 15 cases (10.5%), type Ⅲb, 28 cases (19.6%) and type Ⅳ, 43 cases (30.0%). The patients within the first 10 operation cases in each operation time (the first 10 patients in each operation team) were divided into group A (77 cases), and the patients after 10 cases in each operation time were classified as group B (66 cases); the cases with more than 10 cases in the center were further divided into group A(1) (116 cases), and the center with less than 10 cases was set as group A(2) (27 cases). T test or Wilcoxon test was used to compare the measurement data between groups, and the chi square test or Fisher exact probability method was used to compare the counting data between groups. Kaplan Meier curve was used for survival analysis. Results: All patients successfully completed laparoscopic procedure. The mean operation time was (421.3±153.4) minutes (range: 159 to 770 minutes), and the intraoperative blood loss was 100 to 1 500 ml (median was 300 ml) .Recent post-operative complications contained bile leakage, abdominal bleeding, abdominal infection, gastrointestinal bleeding, and delay gastric emptying, pulmonary infection, liver failure, et al.The post-operative hospital stay was (15.9±9.2) days. The operation time in group B was relatively reduced ( (429.5±190.7)minutes vs. (492.3±173.1)minutes, t=2.063, P=0.041) and the blood loss (465 ml vs. 200 ml) was also reduced (Z=2.021, P=0.043) than that in group B. The incidence of postoperative biliary fistula and lung infection in patients in group A was significantly higher than that in group B (χ(2)=4.341, 0.007; P=0.037, 0.047) .Compared with group A(2), the operation time in group A(1) was relatively reduced( (416.3±176.5)minutes vs. (498.1±190.4)minutes, t=2.136, P=0.034) , the incidence of bile leakage and abdominal cavity infection in group A(1) was lower than that in group A(2) (χ(2)=7.537, 3.162; P=0.006, 0.046) . Kaplan Meier survival curve showed that the difference of short-term survival time between group A and group B was statistically significant (P<0.05) . Conclusions: The completion of laparoscopic hilar cholangiocarcinoma radical surgery is based on improved surgical skills, and proficiency in standardized operation procedures.It is feasible for laparoscopic radical resection of hilar cholangiocarcinoma to well experienced surgeon with cases be strictly screened, but it is not recommended for widespread promotion at this exploratory stage.

[Clavien-Dindo classification and influencing factors analysis of complications after laparoscopic pancreaticoduodenectomy]

Objective: To semi-quantify the postoperative complications occurred after laparoscopic pancreaticoduodenectomy(LPD) using Clavien-Dindo score, thereafter exploring its impact factors. Methods: In this retrospective cohort study, the clinical data of 124 patients who had undergone LPD for periampullary tumor from June 2016 to June 2017 at Department of Biliary Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology were collected.Malignancy was confirmed based on postoperative pathological reports.Postoperative complications were semi-quantitated using Clavien-Dindo score.Multivariable logistic regression model was applied to explore the factors related to severe complications(Clavien-Dindo Ⅲb-Ⅴ). Results: Of the 124 patients, there were 64 males(51.6%) and 60 females(48.4%), with age of 57 years(range, 23-82 years). In total, postoperative complications occurred in 30 patients(24.2%). Among the 30 patients, 4 patients suffered Clavien-Dindo grade Ⅰ, 18 patients(14.5%) suffered Clavien-Dindo grade Ⅱ, 6 patients(4.8%) suffered Clavien-Dindo grade Ⅲa, 1 patient(0.1%) suffered Clavien-Dindo grade Ⅳb, and 1 patient(0.1%) suffered Clavien-Dindo grade Ⅴ.Intraabdominal hemorrhage occurred in 8 patients, pancreatic fistula was found in 10 patients(7 patients had biochemical leakage and 3 of them had grade B pancreatic fistula), both biliary fistula and gastrointestinal fistula were found in 1 patient.Abdominal infection occurred in 10 patients, both liver failure and renal failure occurred in one patient.Moreover, arrhythmia was found in two patients, and mortality occurred in one patient.Five patients suffered multiple complications.Univariable analysis showed that postoperative complications were associated with body mass index, American Society of Anesthesiologists(ASA) score, intraoperative blood transfusion, and pancreatic texture(P<0.05). In multivariable logistic regression, ASA grade Ⅲ, intraoperative blood transfusion, and pancreatic softness were independently related to postoperative complications after LPD(P<0.05). Conclusions: Clavien-Dindo score is feasible to be applied in management of patients with LPD.ASA score, texture of pancreas, and intraoperative blood transfusion were independently associated with postoperative complications.

[The optimization of surgical approach selection and technical process in total laparoscopic pancreatoduodenectomy]

The optimization of surgical approach selection and technical process, and methods of operation safety and radical resection the tumor by total laparoscopic pancreatoduodenectomy are important topics to be explored. Based on practical experiences, the optimization measures of surgical approach selection and technical process in total laparoscopic pancreatoduodenectomy are investigated and described.

Gli1 expression in pancreatic ductal adenocarcinoma and its clinical significance

The aim of this study was to explore the correlation between the expression levels of Gli1 and p53 in pancreatic ductal adenocarcinoma (PDAC) and its pathological significance. Immunohistochemistry (IHC) was employed to measure the expression level of Gli1 and p53 in 85 sets of paraffin-embedded PDAC and corresponding para-carcinoma tissue specimens. The relationship between these results and the respective patients' clinicopathologic parameters was analyzed. IHC staining revealed that the expression levels of Gli1 and p53 in cancer tissues were evidently higher than that of para-carcinoma tissues (P < 0.05); while Gli1 expression levels correlated with the corresponding TNM stage and tumor infiltration depth, p53 expression level correlated with the respective TNM stage (P < 0.05). Taken together, this study demonstrates increased expression of Gli1 and p53 in PDAC, and proves that Gli1 could be apotential biomarker for prognostic judgment.

Systematic review and meta-analysis comparing three techniques for pancreatic remnant closure following distal pancreatectomy

BACKGROUND

Established closure techniques for the pancreatic remnant after distal pancreatectomy include stapler, suture and anastomotic closure. However, controversy remains regarding the ideal technique; therefore, the aim of this study was to compare closure techniques and risk of postoperative pancreatic fistula (POPF).

METHODS

A systematic review was carried out according to PRISMA guidelines for studies published before January 2014 that compared at least two closure techniques for the pancreatic remnant in distal pancreatectomy. A random-effects model was constructed using weighted odds ratios (ORs).

RESULTS

Thirty-seven eligible studies matched the inclusion criteria and 5252 patients who underwent distal pancreatectomy were included. The primary outcome measure, the POPF rate, ranged 0 from to 70 per cent. Meta-analysis of the 31 studies comparing stapler versus suture closure showed that the stapler technique had a significantly lower rate of POPF, with a combined OR of 0.77 (95 per cent c.i. 0.61 to 0.98; P = 0.031). Anastomotic closure was associated with a significantly lower POPF rate than suture closure (OR 0.55, 0.31 to 0.98; P = 0.042). Combined stapler and suture closure had significantly lower POPF rates than suture closure alone, but no significant difference compared with stapler closure alone.

CONCLUSION

The use of stapler closure or anastomotic closure for the pancreatic remnant after distal pancreatectomy significantly reduces POPF rates compared with suture closure. The combination of stapler and suture closure shows superiority over suture closure alone.

Overexpression of an alternative oxidase gene, OsAOX1a, improves cold tolerance in Oryza sativa L

Low temperature is a major environmental stress in rice cultivating and production. The alternative oxidase 1 (AOX1) gene is potentially important for genetic engineering to increase cold adaptation. However, previous studies related to this effect have mostly focused on the dicot plants Arabidopsis and tobacco, whereas functional research on rice is limited. In this study, we cloned a rice predominant cold-response AOX1 gene, OsAOX1a. Transgenic rice plants with overexpression of OsAOX1a were obtained. We found that OsAOX1a overexpression could strongly enhance the cold growth of seedlings, especially with respect to root extension. However, growth between transgenic and control plants did not differ under normal conditions. Furthermore, the lipid peroxidation and ion leakage rate were determined after cold treatment in transgenic plants. Both factors were reduced by OsAOX1a overexpression, which revealed that OsAOX1a could reduce oxidative damage under cold stress. Taken together, our results suggested that overexpressing OsAOX1a could improve growth performance of rice under cold stress, which might be closely related to the reduction of reactive oxygen species generation and oxidative damage.

SRAP analysis of DNA base sequence changes in lotus mutants induced by Fe⁺ implantation

Ion implantation, a new biophysically mutagenic technique, has shown great potential for crop breeding. To reveal the mutation effect of low-energy ion implantation on Baiyangdian red lotus, sequence-related amplified polymorphism markers were used to amplify and detect the DNA sequence differences in mutants induced by Fe(+) ion implantation. A total of 121 primer combinations were tested in 6 mutants and a control. Seven primer combinations (me1 + em3, me1 + em14, me9 + em3, me8 + em2, me6 + em1, me11 + em5, and me6 + em5) generated clear bands with high polymorphism and good repeatability. The results showed that among 15,317 bases cloned, 146 bases in 6 mutants were different from those of the wild type, showing a variation frequency of 0.95%. The types of base changes included deletion, insertion, transversion, and transition. Adenine was more sensitive to the irradiation than were the other bases. The results suggested that mutational "hotspots" probably exists in lotus and are induced by low-energy ion implantation.