Development and multicenter validation of a nomogram for preoperative prediction of lymph node positivity in pancreatic cancer (NeoPangram).

BACKGROUND: Neoadjuvant therapy is associated with nodal downstaging and improved oncological outcomes in patients with lymph node (LN)-positive pancreatic cancer. This study aimed to develop and validate a nomogram to preoperatively predict LN-positive disease. METHODS: A total of 558 patients with resected pancreatic cancer were randomly and equally divided into development and internal validation cohorts. Multivariate logistic regression analysis was used to construct the nomogram. Model performance was evaluated by discrimination, calibration, and clinical usefulness. An independent multicenter cohort consisting of 250 patients was used for external validation. RESULTS: A four-marker signature was built consisting of carbohydrate antigen 19-9 (CA19-9), CA125, CA50, and CA242. A nomogram was constructed to predict LN metastasis using three predictors identified by multivariate analysis: risk score of the four-marker signature, computed tomography-reported LN status, and clinical tumor stage. The prediction model exhibited good discrimination ability, with C-indexes of 0.806, 0.742 and 0.763 for the development, internal validation, and external validation cohorts, respectively. The model also showed good calibration and clinical usefulness. A cut-off value (0.72) for the probability of LN metastasis was determined to separate low-risk and high-risk patients. Kaplan-Meier survival analysis revealed a good agreement of the survival curves between the nomogram-predicted status and the true LN status. CONCLUSIONS: This nomogram enables the identification of pancreatic cancer patients at high risk for LN positivity who may have more advanced disease and thus could potentially benefit from neoadjuvant therapy.

Treatment of hilar cholangiocarcinoma of Bismuth-Corlette type III with hepaticojejunostomy.

AIM OF THE STUDY: The present study aims to explore the value of application of hepaticojejunostomy in surgical treatment of Bismuth-Corlette type III hepatic hilar cholangiocarcinoma. MATERIAL AND METHODS: The clinical data of hepaticojejunostomy in 6 patients with Bismuth-Corlette type III hepatic hilar cholangiocarcinoma from January 2008 to October 2011 were retrospectively analyzed. There were 5 males and 1 female, aged 45-69 years, on average 58 years old. There were 3 cases of Bismuth-Corlette type IIIa and 3 cases of Bismuth-Corlette type IIIb. RESULTS: The 6 patients all successfully underwent hepaticojejunostomy, with operation time of 160-310 min, on average 210 ±28 min. One patient suffered a small amount of bile leakage (3-20 ml) and his drainage tube was taken out after being cured with conservative treatment for 18 days. Three patients showed postoperative mild increases of aspartate aminotransaminase (AST), alanine transaminase (ALT) and AKP, which were improved after drug treatments. There was no biliary stricture in the 6 patients after follow-up for 3-18 months. CONCLUSIONS: Hepaticojejunostomy was simple and flexible, with a good effect on biliary reconstruction of Bismuth-Corlette type III hepatic hilar cholangiocarcinoma. It solved the difficulties in multiple choledochojejunostomy, and with less complications; therefore, it is worth being popularized.

Intestinal malrotation associated with colon cancer in an adult: report of a case.

Intestinal malrotation is a congenital anomaly of intestinal rotation and fixation that generally becomes symptomatic during the neonatal period. However, it rarely occurs in adulthood, and synchronous colon cancer is even rarer. This report presents the case of a 45-year old man who suffered from intestinal malrotation associated with colon cancer.

Complete duodenal obstruction induced by groove pancreatitis: A case report.

BACKGROUND: Groove pancreatitis (GP) is a type of chronic pancreatitis occurring in an anatomic area between the duodenum, head of the pancreas, and common bile duct. Duodenal obstruction is always caused by malignant pancreatic diseases, such as pancreatic head carcinoma, while is rarely induced by benign pancreatic diseases, such as pancreatitis. CASE SUMMARY: A 39-year-old man presented with a 1-mo history of upper abdominal discomfort. His concomitant symptoms were abdominal distension, postprandial nausea, and vomiting. Contrast-enhanced computed tomography of the abdomen showed thickening of the intestinal wall with enhancement of the descending segment of the duodenum, which could not be clearly differentiated from the head of the pancreas. Upper gastrointestinal radiographs and gastrointestinal endoscopy showed a complete obstruction of the descending duodenum. An operation found that a 3-cm mass was located in the "groove part" of the pancreas and oppressing the descending duodenum. Pancreaticoduodenectomy was performed to relieve the obstruction and thoroughly remove the pancreatic lesions. The pathologic diagnosis was pancreatitis. The patient had an uneventful recovery with no complications. CONCLUSION: Because of the special location and the contracture induced by long-term chronic inflammation, our case reminds surgeons that some benign pancreatic diseases, such as GP, can also present with symptoms similar to those of pancreatic cancer. This knowledge can help to avoid an unnecessary radical operation.

Catheterization of the gallbladder: A novel mouse model of severe acute cholangitis.

AIM: To establish a severe acute cholangitis (SAC) model in mice. METHODS: Cholecystic catheterization was performed under the condition of bile duct ligation (BDL). Trans-cholecystic injection of lipopolysaccharide (LPS) was defined as the SAC animal model. Sham operation group, intraperitoneal injection of LPS without BDL group, intraperitoneal injection of LPS with BDL group and trans-cholecystic injection of normal saline with BDL group were defined as control groups. The survival rates and tissue injuries in liver, lungs and kidney were evaluated. RESULTS: Mice in the SAC group showed a time-dependent mortality and much more severe tissue injuries in liver, lungs and kidney, compared with other groups. However, relieving biliary obstruction could effectively reduce mortality and attenuate liver injury in the SAC mouse model. CONCLUSION: Trans-cholecystic injection of LPS under the condition of biliary obstruction could establish a repeatable and reversible mouse model of SAC.

Dual-input two-compartment pharmacokinetic model of dynamic contrast-enhanced magnetic resonance imaging in hepatocellular carcinoma.

AIM: To investigate the feasibility of a dual-input two-compartment tracer kinetic model for evaluating tumorous microvascular properties in advanced hepatocellular carcinoma (HCC). METHODS: From January 2014 to April 2015, we prospectively measured and analyzed pharmacokinetic parameters [transfer constant (Ktrans), plasma flow (Fp), permeability surface area product (PS), efflux rate constant (kep), extravascular extracellular space volume ratio (ve), blood plasma volume ratio (vp), and hepatic perfusion index (HPI)] using dual-input two-compartment tracer kinetic models [a dual-input extended Tofts model and a dual-input 2-compartment exchange model (2CXM)] in 28 consecutive HCC patients. A well-known consensus that HCC is a hypervascular tumor supplied by the hepatic artery and the portal vein was used as a reference standard. A paired Student's t-test and a nonparametric paired Wilcoxon rank sum test were used to compare the equivalent pharmacokinetic parameters derived from the two models, and Pearson correlation analysis was also applied to observe the correlations among all equivalent parameters. The tumor size and pharmacokinetic parameters were tested by Pearson correlation analysis, while correlations among stage, tumor size and all pharmacokinetic parameters were assessed by Spearman correlation analysis. RESULTS: The Fp value was greater than the PS value (FP = 1.07 mL/mL per minute, PS = 0.19 mL/mL per minute) in the dual-input 2CXM; HPI was 0.66 and 0.63 in the dual-input extended Tofts model and the dual-input 2CXM, respectively. There were no significant differences in the kep, vp, or HPI between the dual-input extended Tofts model and the dual-input 2CXM (P = 0.524, 0.569, and 0.622, respectively). All equivalent pharmacokinetic parameters, except for ve, were correlated in the two dual-input two-compartment pharmacokinetic models; both Fp and PS in the dual-input 2CXM were correlated with Ktrans derived from the dual-input extended Tofts model (P = 0.002, r = 0.566; P = 0.002, r = 0.570); kep, vp, and HPI between the two kinetic models were positively correlated (P = 0.001, r = 0.594; P = 0.0001, r = 0.686; P = 0.04, r = 0.391, respectively). In the dual input extended Tofts model, ve was significantly less than that in the dual input 2CXM (P = 0.004), and no significant correlation was seen between the two tracer kinetic models (P = 0.156, r = 0.276). Neither tumor size nor tumor stage was significantly correlated with any of the pharmacokinetic parameters obtained from the two models (P > 0.05). CONCLUSION: A dual-input two-compartment pharmacokinetic model (a dual-input extended Tofts model and a dual-input 2CXM) can be used in assessing the microvascular physiopathological properties before the treatment of advanced HCC. The dual-input extended Tofts model may be more stable in measuring the ve; however, the dual-input 2CXM may be more detailed and accurate in measuring microvascular permeability.

Gastric fistula secondary to drainage tube penetration: A report of a rare case.

Cases of gastric fistula secondary to drainage tube penetration have rarely been reported. The current study presents a case of gastric penetration caused by misplacement of a drainage tube after a splenectomy. The patient was admitted to the Department of Hepatobiliary Surgery, (Shaoxing People's Hospital, Shaoxing Hospital of Zhejiang University, Shaoxing, Zhejiang, China) for blunt abdominal trauma due to injuries sustained in an automobile accident. A ruptured spleen was found and successfully removed surgically. On post-operative day 7, the patient complained of slight discomfort and tenderness in the left upper quadrant of the abdomen. In addition, 500 ml of bile-colored fluid with small food particles was noted in the drainage tube. Barium X-ray revealed a gastric fistula in the upper gastrointestinal tract. Gastroscopy indicated infiltration of the drainage tube into the gastric cavity. No significant peritoneal effusion was observed, as revealed by abdominal ultrasound examination. These results confirmed the diagnosis of a gastric fistula secondary to perforation by the drainage tube. Following conservative treatment with antibiotics and total parenteral nutrition, the general condition of the patient improved significantly. The drainage tube was withdrawn progressively, as the amount of fluid being discharged was decreasing. Gastroenterography confirmed perforation closure and the tube was finally removed on post-operative day 44.

Management of bile duct injuries combined with accessory hepatic duct during laparoscopic cholecystectomy.

Bile duct injuries (BDIs) are difficult to avoid absolutely when the biliary tract has a malformation, such as accessory hepatic duct. Here, we investigated the management strategies for BDI combined with accessory hepatic duct during laparoscopic cholecystectomy.

A huge adenosquamous carcinoma of the pancreas with sarcomatoid change: an unusual case report.

Adenosquamous carcinoma rarely occurs in the pancreas, and is characterized by the presence of cellular components from both duct adenocarcinoma and squamous carcinoma. Here, we describe a rare case of pancreatic adenosquamous carcinoma with sarcomatous change. Immunohistochemistry showed that the sarcomatous lesion lost the epithelial marker and aberrantly expressed of acquired mesenchymal markers, which indicated that this special histological phenotype may be attributed to epithelial-mesenchymal transition. This case also indicated that a routine radical surgery without aggressive treatment strategies was still appropriate for adenosquamous carcinoma of the pancreas with sarcomatoid change.