TRIANGLE operation, combined with adequate adjuvant chemotherapy, can improve the prognosis of pancreatic head cancer: A retrospective study.

BACKGROUND: The TRIANGLE operation involves the removal of all tissues within the triangle bounded by the portal vein-superior mesenteric vein, celiac axis-common hepatic artery, and superior mesenteric artery to improve patient prognosis. Although previously promising in patients with locally advanced pancreatic ductal adenocarcinoma (PDAC), data are limited regarding the long-term oncological outcomes of the TRIANGLE operation among resectable PDAC patients undergoing pancreaticoduodenectomy (PD). AIM: To evaluate the safety of the TRIANGLE operation during PD and the prognosis in patients with resectable PDAC. METHODS: This retrospective cohort study included patients who underwent PD for pancreatic head cancer between January 2017 and April 2023, with or without the TRIANGLE operation. Patients were divided into the PDTRIANGLE and PDnon-TRIANGLE groups. Surgical and survival outcomes were compared between the two groups. Adequate adjuvant chemotherapy was defined as adjuvant chemotherapy ≥ 6 months. RESULTS: The PDTRIANGLE and PDnon-TRIANGLE groups included 52 and 55 patients, respectively. There were no significant differences in the baseline characteristics or perioperative indexes between the two groups. Furthermore, the recurrence rate was lower in the PDTRIANGLE group than in the PDnon-TRIANGLE group (48.1% vs 81.8%, P < 0.001), and the local recurrence rate of PDAC decreased from 37.8% to 16.0%. Multivariate Cox regression analysis revealed that PDTRIANGLE (HR = 0.424; 95%CI: 0.256-0.702; P = 0.001), adequate adjuvant chemotherapy ≥ 6 months (HR = 0.370; 95%CI: 0.222-0.618; P < 0.001) and margin status (HR = 2.255; 95%CI: 1.252-4.064; P = 0.007) were found to be independent factors for the recurrence rate. CONCLUSION: The TRIANGLE operation is safe for PDAC patients undergoing PD. Moreover, it reduces the local recurrence rate of PDAC and may improve survival in patients who receive adequate adjuvant chemotherapy.

Application of omental interposition to reduce pancreatic fistula and related complications in pancreaticoduodenectomy: A propensity score-matched study.

BACKGROUND: The life-threatening complications following pancreatoduodenectomy (PD), intra-abdominal hemorrhage, and postoperative infection, are associated with leaks from the anastomosis of pancreaticoduodenectomy. Although several methods have attempted to reduce the postoperative pancreatic fistula (POPF) rate after PD, few have been considered effective. The safety and short-term clinical benefits of omental interposition remain controversial. AIM: To investigate the safety and feasibility of omental interposition to reduce the POPF rate and related complications in pancreaticoduodenectomy. METHODS: In total, 196 consecutive patients underwent PD performed by the same surgical team. The patients were divided into two groups: An omental interposition group (127, 64.8%) and a non-omental interposition group (69, 35.2%). Propensity score-matched (PSM) analyses were performed to compare the severe complication rates and mortality between the two groups. RESULTS: Following PSM, the clinically relevant POPF (CR-POPF, 10.1% vs 24.6%; P = 0.025) and delayed postpancreatectomy hemorrhage (1.4% vs 11.6%; P = 0.016) rates were significantly lower in the omental interposition group. The omental interposition technique was associated with a shorter time to resume food intake (7 d vs 8 d; P = 0.048) and shorter hospitalization period (16 d vs 21 d; P = 0.031). Multivariate analyses showed that a high body mass index, nonapplication of omental interposition, and a main pancreatic duct diameter < 3 mm were independent risk factors for CR-POPF. CONCLUSION: The application of omental interposition is an effective and safe approach to reduce the CR-POPF rate and related complications after PD.

Low preoperative skeletal muscle index increases the risk of mortality among resectable pancreatic cancer patients: A retrospective study.

BACKGROUND: The only potential curative treatment for patients with pancreatic cancer is surgery; however, the prognosis remains poor. Measures of body composition based on computed tomography (CT) have been established as a reliable predictor of the prognosis of cancer patients after surgery. AIM: To elucidate the associations of body composition measures derived from preoperative CT scans with the prognosis of patients with pancreatic cancer. METHODS: One hundred fifteen patients undergoing pancreatic resection with curative intent for pancreatic cancer were retrospectively enrolled. A preoperative CT scan at the third lumbar vertebral level was performed to measure the skeletal muscle index (SMI), mean skeletal muscle radiodensity, subcutaneous adipose tissue index, and visceral to subcutaneous adipose tissue area ratio. The clinical and pathological data were collected. The effects of these factors on long-term survival were evaluated. RESULTS: Among the five body composition measures, only low SMI independently predicted overall survival (OS) [hazard ratio (HR): 2.307; 95% confidence interval (CI): 1.210-4.402] and recurrence-free survival (HR: 1.907; 95%CI: 1.147-3.171). Furthermore, patients with low SMI (vs high SMI) were older (68.8 ± 9.3 years vs 63.3 ± 8.4 years); low SMI was present in 27 of 56 patients (48.2%) aged 65 years and older and in 11 of 59 younger patients (18.6%). In addition, subgroup analyses revealed that the correlation between low SMI and OS was observed only in patients aged 65 years and older. CONCLUSION: Low preoperative SMI was more prevalent in elderly patients and was associated with a poor prognosis among pancreatic cancer patients, especially elderly patients.

The anatomical features of dorsal pancreatic artery in the pancreatic head and its clinical significance in laparoscopic pancreatoduodenectomy.

BACKGROUND: Bleeding control as one of the major challenges in laparoscopic pancreaticoduodenectomy (LPD) necessitates a considerable anatomical knowledge of the blood supply to the pancreatic head so as to improve the safety of this surgery. This study aimed towards a better understanding of the anatomical features of the dorsal pancreatic artery (DPA), as well as its clinical significance in LPD. METHOD: Thirteen Chinese cadaveric specimens were used to study the blood supply of the pancreatic head. Twelve of them were perfused with latex, and the other fresh one was used to build the intraorganic structure model of the pancreas by mold casting. Between July 2018 and June 2019, a total of thirty-five consecutive patients without vascular encasement, who underwent LPD in our institute, were performed with computed tomography as a preoperative detection of the DPA. The DPA was ligated prior to uncinate process dissection in seventeen patients ("early DPA ligation" group), as the others were assigned into the control group. RESULTS: In the thirteen cadaveric specimens, the DPA originates, respectively, from the splenic artery (46.1%), superior mesenteric artery (38.5%), common hepatic artery (7.7%) and right gastroepiploic artery (7.7%). The right branch of the DPA gives off terminal arteries to form an "inner ring" in the pancreatic head, which communicates with the pancreaticoduodenal arterial arches by plenty of collateral arteries. As compared to the control group, the "early DPA ligation" group showed a significantly lower mean blood loss (218 ± 111 vs 320 ± 162, P = 0.038), as well as shorter mean resection time (121 ± 23 vs 136 ± 22, P = 0.049). CONCLUSION: The DPA is one of the major blood supplies to the pancreatic head. A ligation of DPA prior to dissection of the uncinate process can help to completely block the blood supply to the pancreatic head, and therefore improve surgical outcome and safety in LPD.

Management of the uncinate process via the artery first approach in laparoscopic pancreatoduodenectomy.

BACKGROUND: Uncinate process dissection is one of the major challenges for surgeons when performing laparoscopic pancreatoduodenectomy. This study aimed to evaluate the artery first approach for handling uncinate process dissection in laparoscopic pancreatoduodenectomy. METHODS: Between February 2015 and June 2018, a total of 91 consecutive patients without vascular encasement underwent selective laparoscopic pancreatoduodenectomy, including the first 26 consecutive cases treated with the conventional approach and the remaining 65 with the artery first approach applied for uncinate process dissection. Here, we present and analyze the surgical outcomes and the oncological results for the two groups. RESULTS: There was no significant difference between the two groups in operative time, intraoperative blood loss, the rate of conversion to open pancreatoduodenectomy, postoperative complications, mortality, as well as the number of lymph nodes retrieved in the malignancies. In contrast, the artery first approach group showed a statistically significant shorter resection time and a higher R0 resection rate when compared with the conventional group. CONCLUSIONS: The artery first approach is a safe and feasible technique that can be used for uncinate process management in laparoscopic pancreatoduodenectomy for patients without vascular encasement. It also has the advantage of increased rate of radical resection in the surgical intervention of relevant malignancies.

Resistin aggravates the expression of proinflammatory cytokines in cerulein­stimulated AR42J pancreatic acinar cells.

Resistin, an adipocytokine secreted by fat tissues, has been shown to be associated with increased local and systemic complications in acute pancreatitis (AP). However, the mechanism underlying the effect of resistin in the aggravation of AP remains to be elucidated. The aim of the present study was to investigate the functional consequences of exposing rat pancreatic acinar cells to resistin and to determine whether it amplifies proinflammatory signaling in an in vitro AP model. AR42J cells pretreated with recombinant resistin were activated by cerulein as an in vitro model of AP. The secretion of amylase was measured to evaluate the cytotoxic effect. The mRNA expression levels of tumor necrosis factor (TNF)­α and interleukin (IL)­6 were determined using reverse transcription­quantitative polymerase chain reaction analysis. The nuclear protein expression levels of the nuclear factor (NF)­κB p65 subunit were determined using western blot analysis. Resistin treatment significantly increased the secretion of amylase, and the mRNA expression levels of TNF­α and IL­6 in the cerulein­induced in vitro AP model. High protein levels of the NF­κB p65 subunit were observed in the nuclei of cells in the resistin­treated AP model, compared with the untreated AP model. Pretreatment of the in vitro resistin­treated AP model with the NF­κB inhibitor, pyrrolidine dithiocarbamate decreased the protein expression of the NF­κB p65 subunit in nuclei, and significantly attenuated the increased mRNA expression levels of TNF­α and IL­6 induced by resistin. The results of the present study showed that resistin increased the production of the TNF­α and IL­6 proinflammatory cytokines via the NF­κB­dependent pathway during AP. Thus, the overproduction of obesity­associated resistin and the associated amplification of the inflammatory response may result in the aggravation of AP severity.

Initial experience in total laparoscopic central pancreatectomy with pancreatogastrostomy.

Central pancreatectomy is an ideal treatment option to preserve pancreatic parenchyma and function for the benign and low-grade malignant tumors limited to the pancreatic neck or proximal body of the pancreas. This study presents our initial experience in total laparoscopic central pancreatectomy with pancreatogastrostomy. In 2013, two consecutive patients underwent total laparoscopic central pancreatectomy at our hospital. Data on surgical procedure, post-operative course, and follow-up were evaluated. Both the patients successfully underwent total laparoscopic central pancreatectomy with pancreatogastrostomy. The operating times were 250 and 300 min with blood loss of 100 and 200 ml and post-operative hospital stay of 9 and 10 days, respectively. The first patient did not suffer any post-operative complications. The second patient developed intra-abdominal fluid collection due to pancreatic fistula which was managed by percutaneous drainage. These two patients had no post-operative diabetes mellitus or exocrine insufficiency within the follow-up periods of 14 and 10 months, respectively. Thus, laparoscopic CP is a safe and feasible technique for treating benign and low-grade malignant tumors in the neck or proximal body of the pancreas when performed by highly skilled pancreatic and laparoscopic surgeons.

Expression of the adipocytokine resistin and its association with the clinicopathological features and prognosis of pancreatic ductal adenocarcinoma.

Fat tissue is viewed as an active endocrine organ that secretes a variety of bioactive substances. Resistin, an adipocyte-secreted factor, is thought to be closely related to obesity, insulin resistance and inflammation, the three most significant risk factors for the progression of pancreatic cancer. However, the association between resistin and pancreatic cancer is still unknown. In this study, pancreatic tumor samples from 45 patients with pancreatic ductal adenocarcinoma were analyzed with immunohistochemistry for the expression of resistin. The correlation between resistin expression and clinicopathological features and prognosis were evaluated. Resistin staining was observed in 48.9% (22 of 45) of the cases. Resistin expression was more frequent in poorly differentiated tumors (9 of 9, 100%) compared to moderately differentiated tumors (11 of 28, 39.3%) and well-differentiated tumors (2 of 8, 25%) (p<0.01). The incidence of resistin expression in patients with Japan Pancreas Society stages III-IV (18 of 27, 66.7%) was significantly higher than in subjects with stages I-II (4 of 18, 22.2%) (p<0.01). Patients with resistin-stained tumors had significantly shorter relapse-free survival times (median, 9 months) than patients with negative tumors (median, 18 months) (p<0.05). In addition, multivariate analysis showed that resistin expression was an independent prognostic factor for relapse-free survival of patients with pancreatic ductal adenocarcinoma (p<0.05). These results demonstrate that resistin may influence the progression of pancreatic tumors and may be a useful predictor of relapse-free survival in patients with pancreatic ductal adenocarcinoma.

Increased NPC1L1 and ACAT2 expression in the jejunal mucosa from Chinese gallstone patients.

The incidence of cholesterol gallstones is a very common disease. The aim of this study is to probe for underlying intestinal molecular defects associated with development of gallstones. Twelve Chinese patients with cholesterol gallstone disease (GS) and 31 gallstone-free (GSF) patients were investigated. Quantitation of mRNA levels for individual genes in mucosal biopsies from jejunum was carried out with real-time PCR. The frequency of two SNPs in the ABCG8 gene (Y54C and T400K) was determined by allelic discrimination. The intestinal mRNA expression of NPC1L1 and ACAT2 were significantly higher in GS than GSF (P<0.05). No differences were observed concerning the levels for plasma lipids, plant sterols and 7alpha-hydroxy-4-cholesten-3-one between GS and GSF. No correlations were observed between patients carrying the different genotypes for Y54C or T400K and their mRNA levels for ABCG5 or ABCG8. The increased NPC1L1 and ACAT2 mRNA levels in gallstone patients might indicate an upregulated absorption and esterification of cholesterol in the small intestine.

Clinical characteristics of acute pancreatitis patients with elevated serum triglyceride concentration.

OBJECTIVE: To evaluate the clinical characteristics of acute pancreatitis (AP) patients with elevated serum triglyceride (TG) concentration. METHODS: Ninety-nine cases of AP admitted from January 2000 to January 2002 were analyzed: 28 cases comprised the TG-elevated group (serum TG >1.7 mmol/L) and 71 cases were the TG-normal group (serum TG