[The clinical analysis of autoimmune pancreatitis: a report of 21 cases].

OBJECTIVE: To investigate the clinical feature, diagnostic and therapeutic experience of autoimmune pancreatitis (AIP). METHODS: Twenty-one patients with AIP treated in the First Affiliated Hospital, Harbin Medical University from January 2006 to July 2014 were analyzed retrospectively. There were 15 men and 6 women among the 21 cases and the age ranged from 36 to 64 years. The characters of diagnosis and treatment of AIP were explored through clinical symptoms, imaging features, serologic test results, diagnostic treatment, and histopathologic characteristics. RESULTS: All the patients showed obstructive jaundice and upper abdominal pain to different extents as major manifestations and the levels of serum IgG4, CA19-9, CEA were elevated in 16 cases (76.2%), 6 cases (28.5%) and 3 cases (14.2%), respectively. CT showed diffuse enlargement of the pancreas in 9 cases, localized pancreatic head enlargement in 3 cases and focally pancreatic mass in 9 cases. AIP was confirmed by extrapancreatic involvement, radiological and serological results plus biopsy in 11 cases (52.4%), interpretation of response to steroid in 3 cases (14.3%) and open laparotomy in 7 cases (33.3%). Surgery included choledochojejunostomy in 3 cases, cholecystojejunostomy in 1 case, pancreaticoduodenectomy in 2 cases and distal pancreatectomy combined with splenectomy in 1 case. The pathologic results displayed massive lymphocytes and plasma cells infiltration in the pancreatic tissues as well as parenchymal fibrosis. Except for 1 patient who had no symptom, the regular steroid therapy was performed (oral prednisone) and all the patients were cured. The follow-up time range was from 3 to 93 months, 4 cases (19.0%) were recurrent followed by the symptoms alleviated after the steroid was applied again. CONCLUSIONS: AIP is rare and characterized by non-specific clinical manifestations so that the early diagnosis is difficult with a high misdiagnosis rate. The clinicians should strengthen the recognition of AIP and the definite diagnosis depends on the combination of clinical manifestations, radiological, serological and histopathological results so as to avoid the unnecessary operation.

[A prospective randomized controlled trial of pancreatic duct stent internal versus external drainage with pancreaticojejunostomy for the early curative effect after pancreaticoduodenectomy].

OBJECTIVE: To investigate the effect of pancreatic duct stent internal versus external drainage with pancreaticojejunostomy on the early curative effect after pancreaticoduodenectomy (PD). METHODS: The study was a prospective controlled trial. A total of 219 patients undergoing PD from January 2010 to March 2013 were randomly divided into external drainage group (n = 110) and internal drainage group (n = 109). The pancreatic duct stent was put in the jejunum during the operation in the internal drainage group, while that in the external drainage group was placed outside the body through the jejunum and abdominal wall. The intra-operative blood loss, operative duration, post-operative hospital stay, mortality rate, and the morbidity of pancreatic fistula as well as other complications were compared between the two groups. RESULTS: Compared with internal drainage group, pancreatic duct stent external drainage obviously reduced the morbidity of pancreatic fistula (13.6% vs. 22.6%), delayed gastric emptying (10.0% vs. 27.5%), abdominal infection (6.4% vs. 19.3%), intestinal obstruction (8.2% vs. 20.2%) along with the overall complications (24.5% vs. 41.3%) after PD (χ(2) = 5.735 8 to 11.047 7, P < 0.05), and shortened the healing duration of pancreatic fistula ((11.5 ± 2.9) d vs. (20.1 ± 5.7) d, t = 5.07, P < 0.01), while there was no significant difference in the intra-operative blood loss, operative duration, post-operative hospital stay and mortality rate, etc between the two groups (P > 0.05). CONCLUSIONS: Pancreatic duct stent external drainage can effectively reduce the morbidity of pancreatic fistula and the overall complications after PD, which is safe and feasible. The method is worthy of popularization and application clinically.

[The clinical analysis of a step-up approach for severe acute pancreatitis: report of 121 cases].

OBJECTIVE: To investigate the feasibility and clinical value of the step-up approach for severe acute pancreatitis (SAP). METHODS: Clinical data of 121 SAP patients admitted between January 2002 and December 2011 were retrospectively analyzed. Fifty-eight patients (37 males and 21 females, aged from 20 to 72 years, mean 47.6 years) in the group of direct open necrosectomy from January 2002 to December 2006 were performed laparotomy through removal of all necrotic tissue. Sixty-three patients (42 males and 21 females, aged from 19 to 78 years, mean 46.2 years) of step-up approach from January 2007 to December 2011 underwent percutaneous catheter drainage through retroperitoneum or omental bursa guided by B-type ultrasonography for the first therapy, and then, according to the pathogenetic condition, if necessary, followed by a small incisional necrosectomy along the drainage tube. The two groups were compared for the rates of postoperative complications, death, transfusion and length of stay, medical costs. RESULTS: The rates of total postoperative complications, organ dysfunction, alimentary tract fistula and incisional hernia in step-up approach group were significantly lower than those of direct open necrosectomy group (31.7% vs. 62.1%, 14.3% vs. 37.5%, 6.3% vs. 19.0%, 9.5% vs. 29.3%; χ(2) = 4.43 to 11.17, P = 0.001 to 0.035). The other complications had no significant differences between the two groups (P > 0.05). Patients in step-up approach group had a lower rates of transfusion (44.4% vs. 70.7%, χ(2) = 8.488, P = 0.004), fewer medical costs of transfusion and hospital stay, compared with those in direct open necrosectomy group ((2525 ± 4573) yuan vs. (4770 ± 6867) yuan, t = 2.131, P = 0.035; (171 213 ± 50 917) yuan vs. (237 874 ± 67 832) yuan, t = 2.496, P = 0.014). There were no significant differences of length of stay and mortality between two groups (P > 0.05). CONCLUSION: Step-up approach for SAP which can reduce the rates of postoperative complications, transfusion and medical costs has significant feasibility and great clinical value.

Anatomic Characteristics, Identification, and Protection of the Nonrecurrent Laryngeal Nerve during Thyroidectomy.

Objective We aimed to investigate the anatomical features and variation pattern of the nonrecurrent laryngeal nerve (NRLN), summarize the methods for identifying the NRLN before and during thyroidectomy, and share experiences regarding preventing and treating its injury. Study Design Retrospective case data analysis. Setting First Affiliated Hospital of Harbin Medical University. Subjects and Methods Between January 2002 and May 2016, 7392 patients underwent thyroidectomy in our hospital. Of them, 28 patients with NRLN were identified, and their clinical data were retrospectively analyzed. Results This study included 7392 patients in which the recurrent laryngeal nerves (RLNs) were routinely identified during surgery. The presence of NRLN was intraoperatively confirmed in 28 patients. All the NRLNs were located on the right side and its overall incidence was 0.37%. Five of the NRLNs were classified as type I, 19 as type IIa, and 4 as type IIb. Of the 28 cases, 4 NRLNs were injured during surgery, in which primary end-to-end anastomosis or local seal with corticosteroid injection was performed as a remedy. In the 4 patients with NRLN injury, 2 presented with postoperative hoarseness that indicated vocal cord paralysis confirmed by laryngoscope; the other 2 patients' voices had no significant changes. Conclusion The NRLN, which is rare in clinical practice and predominantly right-sided, is anatomically more complex and variant at a higher risk of surgical injury. The key factors to accurately identify NRLN and to effectively prevent its injury include careful interpretation of auxiliary examination results before surgery, raising awareness of its presence, meticulous dissection, and routine exposure of the RLN during surgery.