[Operation evaluation: duodenum-preserving pancreatic head resection].

With the improvement of surgical techniques and deeper anatomical understanding, the concept of precision surgery has gradually developed. The necessity of traditional extensive organ resection for the treatment of benign and borderline tumors is being challenged due to the high risk of long-term complications. Over the past 40 years, various modified surgical techniques have emerged, with duodenum-preserving pancreatic head resection as a representative procedure. The surgical indications have gradually transitioned from chronic pancreatitis to benign and borderline tumors of the pancreatic head. The extent of resection has evolved from major partial resection and subtotal resection to total resection of the pancreatic head. The surgical approach has also progressed from traditional open surgery to minimally invasive techniques such as laparoscopic or robot-assisted surgery, reflecting updates and optimizations in treatment concepts and surgical methods. This paper discusses the development, surgical indications, and related complications of duodenum-preserving pancreatic head resection. The aim is to provide a reference for the more standardized and rational selection of this surgical procedure in clinical practice while reducing the incidence of complications.

Exploration of the influence of early rehabilitation training on circulating endothelial progenitor cell mobilization in patients with acute ischemic stroke and its related mechanism under a lightweight artificial intelligence algorithm.

OBJECTIVE: This work aimed to explore the application of lightweight artificial intelligence algorithms in magnetic resonance imaging (MRI) image processing of patients with acute ischemic stroke (AIS) to clarify the effect and mechanism of early rehabilitation training on the mobilization of circulating endothelial progenitor cells (EPCs) in AIS. PATIENTS AND METHODS: A total of 98 AIS patients undergoing MRI examination were selected as the research objects and were randomly divided into a rehabilitation group (early rehabilitation training, 50 cases) and a routine group (conventional treatment, 48 cases) by random number table method and lottery method. In this work, based on the convolutional neural network (CNN) algorithm, a low-rank decomposition algorithm was introduced to optimize it, and a lightweight MRI image computer intelligent segmentation model (LT-RCNN) was established. The LT-RCNN model was used in the MRI image processing of AIS patients, and the role of the model in AIS image segmentation and lesion localization was analyzed. Furthermore, flow cytometry was used to detect the number of peripheral circulating EPCs and CD34+KDR+ cells in the two groups of patients before and after treatment. The serum levels of vascular endothelial growth factor (VEGF), tumor necrosis factor-α (TNF-α), interleukin 10 (IL-10), and stromal cell-derived factor-1α (SDF-1α) content were detected by Enzyme-Linked Immunosorbent Assay (ELISA). In addition, the correlation between each factor and CD34+KDR+ was analyzed by Pearson linear correlation. RESULTS: The diffusion-weighted imaging (DWI) signal of MRI images of AIS patients under the LT-RCNN model was high. The location of the lesion could be accurately detected, and the contour of the lesion could be displayed and segmented, and the segmentation accuracy and sensitivity were significantly better than before optimization. The number of EPCs and CD34+KDR+ cells in the rehabilitation group was increased compared with the control group (p<0.01); the expression levels of VEGF, IL-10, and SDF-1α were higher than those of the control group (p<0.001), and TNF-α content was lower than the control group (p<0.001). The number of CD34+KDR+ cells was positively correlated with VEGF, IL-10, and TNF-α contents (p<0.01). CONCLUSIONS: The results showed that the computer-intelligent segmentation model LT-RCNN could accurately locate, and segment AIS lesions and the early rehabilitation training could change the expression level of inflammatory factors and further promote the mobilization of AIS circulation EPCs.

[Current status and prospects of neoadjuvant therapy for resectable pancreatic cancer].

Pancreatic cancer is a highly malignant tumor. About 75% of patients with pancreatic cancer who underwent radical surgical resection will still experience postoperative recurrence. Neoadjuvant therapy could improve outcomes in patients with borderline resectable pancreatic cancer,has become a consensus;however it is still controversial in resectable pancreatic cancer. Limited high-quality randomized controlled trial studies support the routine initiation of neoadjuvant therapy in resectable pancreatic cancer. With the development of new technologies, such as next-generation sequencing, liquid biopsy, imaging omics, and organoids, patients are expected to benefit from the precision screening of potential candidates for neoadjuvant therapy and individualized treatment strategy.

[Current surgical concepts and future perspectives in the treatment of pancreatic cancer].

Over the past 20 years, the concept of pancreatic surgery has been updated and surgical skills has improved dramatically. With the significant improvement of surgical safety and increase of resection rate for pancreatic cancer, some traditional surgical issues such as surgical indications, timing and extent of resection are being re-evaluated. The improvement of patients' prognosis is the gold standard for judging the surgical indications. The traditional criteria of "unresectable" based on morphology will be constantly broken through, and the estimation of resectability will transition from "what can we resect" to "what should we resect". Except for clinical research, standard extent of lymph node dissection is recommended. However, for borderline resectable and locally advanced pancreatic cancer after neoadjuvant treatment, extended lymph node dissection is recommended. All kinds of surgical approaches are feasible. The approach is subject to the needs of anatomy, anatomy is subject to the needs of radical treatment, and radical treatment is subject to the needs of improving prognosis. For some patients with locally advanced pancreatic cancer, sub-adventitial divestment of superior mesenteric artery and "Heidelberg triangle" cleaning are helpful to improve the resection rate and reduce the local recurrence rate,however, the impact on the long-term prognosis still needs to be further observed clinically. The quality of pancreaticojejunostomy has more influence on the incidence of pancreatic fistula than the type of pancreaticojejunostomy. For the centers with high volume patients and the surgeons with rich personal experience, laparoscopic or robot assisted surgery has the advantages of minimally invasive, but for pancreatic head carcinoma, it is not enough evidence to prove the oncological advantages of laparoscopic pancreaticoduodenectomy and robotic-assistant pancreaticoduodenectomy.

[How to standardize the enhanced recovery after surgery in clinical practice?]

The enhanced recovery after surgery (ERAS) protocol is an evidence-based perioperative care pathway, which is to reduce the perioperative stress and metabolic variation, with the ultimate goal of improving patient recovery and outcomes. This article reviews some hot issues in the clinical practice of ERAS in China. Currently, the concept and pathways of ERAS are very consistent with China's medical reform, and the basic principle of "safety first, efficiency second" should be adhered to. In specific clinical practice, multidisciplinary cooperation, the improvement of surgical quality and the implementation of prehabilitation pathway should be advocated. In addition, the ERAS approaches should be implemented individually to avoid mechanical understanding and dogmatic implementation. The implementation of ERAS and its clinical outcome should be audited to accumulate experience, and a feedback mechanism should be established to improve the outcome continuously. In clinical practice, "fast recovery" should not be the sole purpose. For patients, the decrease in the risk of readmission rate is more important as compared to discharge rate. Additionally, the disparities between the development of ERAS clinical research in China and that in the world are also analyzed in this review. A national ERAS database should be established on the basic platform of academic groups to ensure the development of high-quality clinical research in China.

[The criteria of resectability for pancreatic ductal adenocarcinoma:tumor anatomy or tumor biology?]

Anatomical resectability criteria based on radiologic findings for pancreatic ductal adenocarcinoma has been the main or even the only criterion in practice for a long time. The anatomical criteria has played a very positive role in standardizing surgical indication and restricting medical behavior. However,in the current era of systematic treatment,the limitations of anatomical criteria are becoming increasingly prominent. Although the biological criteria which can be used to evaluate the resectability of pancreatic cancer is still very limited,the comprehensive benefit of CA19-9,PET-CT,neoadjuvant therapy,gene detection and so on can still provide a reference for the evaluation of the resectability of pancreatic cancer. At present,the evaluation of resectability of pancreatic cancer should still adhere to the basic principle of taking anatomical criteria as the basis,biological criteria as the guide,and improving the prognosis of patients as the goal.

[The comparison of prognosis and risk factors after radical resection for pancreatic ductal adenocarcinoma between China Pancreas Data Center and SEER].

Objectives: To compare the prognosis of patients underwent radical resection for pancreatic ductal adenocarcinoma(PDAC) in Surveillance, Epidemiology, and End Results(SEER) and China Pancreas Data Center(CPDC), and to compare the prognostic factors for PDAC in both databases. Methods: The data of patients underwent radical resection for PDAC in CPDC database from January 2016 to December 2017 and SEER database from January 2014 to December 2015 were retrospectively analyzed. The prognosis of patients in both databases was analyzed by the Kaplan-Meier method, Log-rank method, and propensity score matching, and the Cox proportional hazard regression was used to analyze the independent prognosis factors for PDAC. Results: There were 1 977 cases and 2 220 cases of pancreatic cancer that underwent radical resection from CPDC and SEER, respectively. There were more male patients(60.90%,1 204/1 977) than female patients(39.10%,773/1 977) in CPDC, while nearly 1∶1 ratio(male:1 112 cases,female:1108)was observed between male and female in SEER(χ²=48.977,P<0.01). The proportion of patients under 45 years old was the smallest in both databases, and the age group with the most significant proportion was 60 to 74 years old. The ratio of patients over 75 years old in the SEER(24.28%,539/2 220) was higher than that of CPDC(7.89%,156/1 977)(χ²=202.090,P<0.01), while the proportion of patients between 45 and 59 years old in CPDC(33.69%,666/1 977) was higher than that in SEER(19.77%,439/2 220)(χ²=103.640,P<0.01). There were more pancreatic head cancers than body and tail cancers in both databases, and no statistical difference was found in tumor size between the two databases (W=2 181 502,P=0.740). More positive and examined lymph nodes were found in SEER patients (W=3 265 131,W=2 954 363,all P<0.01); and the proportion of patients who had at least 15 lymph nodes dissected was higher in SEER(63.24%,1 404/2 220)(χ²=532.130,P<0.01). There were more patients without neoadjuvant or adjuvant therapy in CPDC(57.16%,1 130/1 977) than that in SEER(24.91%,553/2 220)(χ²=451.390,P<0.01). After propensity score matching, the overall survival for CPDC was better than that for SEER(Log-rank test:χ²=4.500,P=0.034), and the median overall survival was 24 months and 23 months respectively. Cox regressional analysis showed the common independent prognosis factors in both databases were ≥75 years old, pancreatic head cancer, poorly differentiated and undifferentiated tumors, T stage, N stage(All P<0.05). Neoadjuvant or adjuvant therapy was a protective factor in both databases(CPDC:Wald=27.082;SEER:Wald=212.285, all P<0.01) and 45 to 59 years old was protective factor in the SEER database(Wald=5.212,P=0.020). Conclusions: The data in both databases have a good consistency. However, in terms of data quality, examined lymph nodes count, and neoadjuvant/adjuvant therapy rate, the CPDC differs greatly from the SEER.

[Implementation and controversies of enhanced recovery after surgery in pancreaticoduodenectomy].

The concept of enhanced recovery after surgery(ERAS) has been widely accepted and applied in clinical practice.However,as one of the most complex surgical procedures in abdominal surgery,pancreaticoduodenectomy is characterized by long operation time,high incidence rate of postoperative complications and delayed recovery,there still remain some controversies about application of ERAS approaches in perioperative managements of pancreaticoduodenectomy.Although more and more studies has revealed the safety and efficacy of ERAS approaches in pancreaticoduodenectomy,the implementation of ERAS approaches should be still individualized in clinical practice to ensure safety of the patients.

Effects of TGF-ß1 on the expression of endometrial stromal cell-related protein and mRNA.

OBJECTIVE: To investigate the effects of transforming growth factor ß1 (TGF-ß1) on α-smooth muscle actin (α-SMA), insulin-like growth factor I (IGF-I), and type I collagen (Col I) expression in endometrial stromal cells as well as on fibronectin (FN) level. PATIENTS AND METHODS: 56 patients with normal endometrial tissue obtained from surgery were selected from June 2018 to November 2019. Endometrial stromal cells were isolated from patients and then assigned to the control group and observation group (addition of TGF-ß1) followed by the analysis of cellular activity by Thiazole blue staining; and α-SMA, IGF-I, Col I, and FN mRNA and protein levels by real-time fluorescent PCR and Western blot. RESULTS: The cell proliferation rate at 12 h, 24 h, 36 h, and 72 h after culture in both groups was higher than 0 h (p < 0.05) with higher cell proliferation in the observation group than the control group (p < 0.05). Real-time fluorescence PCR results showed that the levels of α-SMA, IGF-I, Col I, and FN mRNA in endometrial stromal cells of the observation group after TGF-ß1 intervention were higher than those in the control group (p < 0.05). Meanwhile, α-SMA, IGF-I, Col I, and FN protein level was also elevated in the observation group after TGF-ß1 treatment (p < 0.05). CONCLUSIONS: TGF-ß1 can stimulate the proliferation of endometrial stromal cells, which may be related to regulate α-SMA, IGF-I, Col I, and FN expression.

[Manual suture or stapler closure: management of pancreatic stump during distal pancreatectomy].

Postoperative pancreatic fistula is the most common complication after distal pancreatectomy.With the update of the domestic and international guidelines or consensuses, the definition of pancreatic fistula has become more standardized.And the classification of pancreatic fistula is able to represent the severity of clinical outcomes more accurately.Currently, the determination of risk factors of pancreatic fistula after distal pancreatectomy, the establishment of prediction model, and the surgical closure mode of pancreatic stump still remain the major topics.With the rapid development of laparoscopic and robotic surgery in pancreatectomy, there are more and more selectionsin transection and managing the pancreatic stump after distal pancreatectomy for prevention of pancreatic fistula.However, there has not been a uniform fashion in terms of manual suture or stapler use to close the pancreatic stump.Herein the current status and development of pancreatic fistula after distal pancreatectomy are reviewed.The strategy of managing the pancreatic stump after distal pancreatectomy should be adopted individually according to the texture and thickness of pancreatic parenchyma.

[Current research status and progress in comprehensive diagnosis and treatment of pancreatic cancer in the era of targeted therapy].

The incidence of pancreatic cancer (PC) has continuously shown an upward trend all over the world. It remains one of the most challenging malignant tumors in clinical practice and is characterized by difficult diagnosis in early stages, low surgical resection rate and poor prognosis. Due to its significant genetic heterogeneity, there are notable individual differences in disease progression, clinical efficacy, sensitivity to chemoradiotherapy, and prognosis among PC patients. In-depth study is needed to reveal the molecular biological characteristics of different PC subtypes and their correlation with clinical manifestations and chemoradiotherapy sensitivity, which could contribute to develop corresponding targeted therapeutic strategies.It is not only the fundamental basis for the innovation of PC morphological classification to molecular subtyping, but also a prerequisite for achieving a shift in treatment mode from "standard therapeutic strategy for different diseases" to "treat the same disease with different strategies" .This article reviews several hot issues on the comprehensive diagnosis and treatment of PC in the era of targeted therapy and prospects its future development.

[The effect of standardized lymphectomy and sampling of resected lymph nodes on TNM staging of resectable pancreatic head cancer].

Objective: To examine the effect of standardized lymphectomy and sampling of resected lymph nodes (LN) on TNM staging of resectable pancreatic head cancer. Methods: Consecutive patients with resectable pancreatic head cancer who received standard pancreatoduodenctomy at Department of General Surgery in Beijing Hospital from December 2017 to November 2018 were recruited as study group. After operation, the surgeon sampled lymph nodes from the fresh specimen following the Japanese Gastric Cancer Guidelines.Thirty-three cases were recruited in the study group and the mean age was (59.8±15.2) years.Pathologic reports from December 2015 to November 2016 were taken as control group, containing 29 cases with age of (57.0±13.0) years. Number of lymph nodes, standard-reaching ratio and positive nodes ratio were compared between two groups. According to the seventh edition and eighth edition of TNM staging, the changes of N staging and TNM staging were analysed. The quantitative data conforming to normal distribution were tested by independent sample t test, the quantitative data not conforming to normal distribution were tested by rank sum test, and the enumeration data were analysed by χ(2) test. Results: The basal data of the two groups were comparable (all P>0.05) . The number of lymph nodes sampled in the study group was 23.27±8.87, significantly more than in control group (12.86±5.90, t=0.653, P=0.000) .Ratio of cases with more than 15 nodes was 81.8% (27/33) in the study group and 34.5% (10/29) in the control group with statistical significance (χ(2)=14.373, P=0.000) . In the study group, the positive lymph node ratios of No. 17a+17b, 14a+14b, 8a+8p LN were 36.4% (12/33) , 30.3% (10/33) and 9.1% (3/33) respectively. The positive lymph node ratio in No.14a+14b LN was higher than in No.8 LN (χ(2)=4.694, P=0.030) . According to the change in N staging system in the AJCC eighth edition, 2 cases (6.1%, 2/33) changed from ⅠB to ⅡA, 7 cases (21.2%, 7/33) from ⅡA to ⅠB and 5 cases (15.2%, 5/33) changed from ⅡB to Ⅲ (25.0%, 5/20) . Conclusions: No.14 LN should be treated as the first station rather than second station because of the anatomic character and higher metastatic ratio. Standardised lymphectomy and sampling may increase the number of LN resected and improve the TNM staging of resectable pancreatic head cancer.

[Circulating tumor cells in pancreatic cancer patients: progression in the detection methods and clinical application].

Circulating tumor cells (CTC) disseminate from primary tumors by undergoing epithelial mesenchymal transition that allow their entry into the circulation to drive metastatic formation in pancreatic cancer patients.Technological advances in detection and characterization of CTC are conducive to the early diagnosis, differential diagnosis, monitoring disease progression and predicating the probability of canceration or the chemotherapeutic efficacy. Nowadays, detection methods of CTC can be based on immunomagnetic beads technique, cell filtration or microfluidic chips technology, but there are great differences in the sample throughput, CTC recovery rate, purity, and CTC viability among them.Owing to the dilemma in detection methods, the intrinsic relevance between the biological characteristics of CTC and clinical manifestations is still not exactly elucidated. By the improved methodology, next generation sequencing technology and exploring the technique for culturing CTC in vitro and establishing xenotransplanted tumor model in nude mice, more and more biological information will be revealed, and finally, individualized treatment is achieved.

HCCS1 inhibits the stemness of human pancreatic cancer stem-like cells.

OBJECTIVE: SW1990-spheroid enrichment (SW1990-SE) cells were isolated using a new type of consecutive spheroid enrichment in this study. Cell surface markers were determined by flow cytometry for identification. In vivo tumorigenicity was applied by subcutaneous transplantation in nude mice for verifying the stemness characteristics of SW1990-SE cells. MATERIALS AND METHODS: SW1990-SE cells were subjected to lentivirus infection for establishing the SW1990-SE cell line stably low-expressing HCCS1 (SW1990-SE-shHCCS1) and negative control cell line (SW1990-SE-LV3NC). The stemness regulatory effects of HCCS1 on SW1990-SE cells were evaluated by cell counting kit-8 (CCK-8) assay and 96-wells plate single cell cloning assay in vitro. Subcutaneous transplantation in nude mice was conducted for evaluating the in vivo stemness regulation of HCCS1 on SW1990-SE cells.. RESULTS: HCCS1 knockdown in SW1990-SE cells did not markedly change the cell proliferation and doubling time, whereas the in vitro spheroid diameter and single cell cloning efficacy remarkably increased. In vivo experiments showed that HCCS1 knockdown greatly enhanced the tumorigenicity of SW1990-SE cells in nude mice. CONCLUSIONS: This study first obtains the human pancreatic cancer stem-like cells SW1990-SE through consecutive spheroid enrichment. Both in vivo and in vitro experiments verified that HCCS1 knockdown largely enhanced the stemness of SW1990-SE cells. Our study provides an important reference for the research of tumor stem cells.

[Diagnosis and treatment of pancreatic neuroendocrine neoplasmas in Von Hippel-Lindau syndrome].

Von Hippel-Lindau(VHL) syndrome is a rare autosomal dominant hereditary disease, and pancreas is one of the frequently involved intra-abdominal organs, including simple pancreatic cysts, pancreatic serous cystadenomas and neuroendocrine neoplasmas. Most of the VHL-related pancreatic neuroendocrine neoplasmas (VHL-pNEN)were non-functional, but they still have a tendency to be malignant. Treatment options for VHL-pNEN include regular follow-up, surgical resection, and medication therapy. When compared with sporadic pNEN, the malignant degree of VHL-pNEN is lower, with a better prognosis, so the surgical treatment should be carefully considered. The indications of surgery for VHL-pNEN include big primary lesions (≥3 cm), fast tumor doubling time (<500 days), VHL gene mutation on exon 3, malignant manifestations on imaging findings, and functional pNEN lesions. The function-preserving approach should be performed to keep the functional pancreatic parenchyma as much as possible. Even for patients with a late stage malignancy that cannot be radically resected, active medication therapy may still lead to a long-term survival.

[The robot-assisted system YunSRobot for soft endoscopy: a trial of remote manipulation on simulation models].

Objective: To evaluate the feasibility and safety of the robot-assisted system YunSRobot for remote manipulation endoscopy. Methods: When the master of YunSRobot was installed in the gastroenterology office in Chinese PLA General Hospital, the robot slave and upper gastrointestinal simulation model (Takahashi Lm103, Japan) were installed at the same time in the State Key Laboratory of Robotics, Shenyang Institute of Automation. Three physicians were trained to operate the master robotics and performed gastroscopy on the simulation model based on network cloud. Each physician performed 3 procedures of oesophagogastroduodenoscopy (EGD) by YunSRobot using traditional manual endoscopy, on-site operating mode, and remote manipulation mode, respectively. The operating time, lumenal anatomic exposure, man-machine interaction and other parameters were recorded. Results: The number of standard pictures obtained by traditional manual endoscopy group, on-site operating group and remote manipulation group were 39.9±0.3, 39.8±0.4, 39.9±0.3, respectively. The images of all five lesions could be obtained by each operation. The operating time in the duodenum of remote group was longer than that of on-site group, with average time (78.2±16.0)s vs. (68.9±15.8)s (P=0.021) respectively. As to the operating time on other parts or total time, all three groups were comparable. Although there was a mean delay of (572.1±48.5) ms in remote operation group, the operation was still smooth. However, compared with on-site group, the percentage of clear view time in the duodenum was significantly shortened in remote group: [(77.8±8.2)% vs. (83.9±6.4)%, P=0.024]. Statistically significant difference was detected in percentage of clear view time neither in other sites, nor was in the total operating time between two groups. The operating time in each part of remote group was obviously longer than that of manual group as followings, pharyngeal (27.3±4.2) s vs. (9.2±1.3)s (P<0.001), esophageal (29.7±6.4)s vs. (19.3±1.6)s (P=0.004), stomach (56.7±17.0)s vs. (40.3±7.0)s (P=0.003), pylorus (20.2±5.5)s vs. (9.3±1.3)s (P<0.001), duodenum (78.2±16.0)s vs. (29.3±5.6)s (P<0.001). Thus the total operating time was also longer in remote group as (559.0±87.2)s vs. (253.1±16.6)s (P<0.001). The respective time in pharynx, esophagus, stomach, pylorus, duodenum, or the overall time was all longer in remote group than that in manual group. Conclusions: The soft endoscopy robot YunSRobot has satisfactory safety and stability. Remote upper gastrointestinal endoscopy can be completed based on common network and an endoscope simulation model with smooth operation. The inspection time by YunSRobot robot per part and the overall time are longer than those of manual operation on site, still, remote operating time meets the standard of upper gastrointestinal endoscopy.

[Sinus pericranii in adults: clinical features and therapeutic management (13 cases report)].

Objective: To study the character of sinus pericranii in the adults and enhance the levels of the diagnosis and treatment of sinus pericranii. Methods: The clinical data of 13 adult patients with sinuses pericranii undergoing surgery in Beijing Hospital from 1992 to 2016 were analyzed retrospectively, including clinical manifestations, imaging data, surgical results. Results: Each of the patients presented with a nonpulsatile and soft tissue mass in their heads.Their ages ranged from 18 to 48 years (mean, 26 years). The diagnosis of the sinus pericranii was made by the clinical manifestations combined with CT and/or MRI examinations.The sinus pericranii did not play the main role in the drainage of the cerebral vein blood.All the patients were cured.The follow up time was from 6 months to 20 years with no sinus pericranii recurrence in all the patients. Conclusions: The analysis of the drainage pattern of sinus pericranii was necessary before surgery in order to get a safe and good operation.The curative effect of the surgery on the sinus pericranii in adult was reliable.