[Distal pancreatectomy with celiac axis resection for pancreatic body cancer: a single center review of 89 consecutive cases].

Objective: To investigate the clinical efficacy of distal pancreatectomy with celiac axis resection(DP-CAR). Methods: A total of 89 consecutive patients (50 males and 39 females) who were diagnosed with pancreatic body cancer and underwent DP-CAR in Pancreas Center,First Affiliated Hospital of Nanjing Medical University between September 2013 and June 2022 were retrospectively reviewed. There were 50 males and 39 females,with age(M(IQR)) of 63(12) years(range:43 to 81 years). Perioperative parameters,pathology results and follow-up data of these patients were analyzed,χ2 or Fisher's test for categorical data while the Wilcoxon test for quantitative data. Survival results were estimated by the Kaplan-Meier survival method. Results: Among 89 cases,cases combined with portal vein-superior mesenteric vein or organ resection accounted for 22.5% (20/89) and 42.7% (38/89),respectively. The operative time,blood loss and postoperative hospital stay were 270 (110) minutes,300 (300) ml and 13 (10) days,respectively. The overall morbidity rate was 67.4% (60/89) while the major morbidity was 11.2% (10/89). The increase rate in transient liver enzymes was 42.7% (38/89),3.4% (3/89) for liver failure,53.9% (48/89) for clinically relevant postoperative pancreatic fistula,1.1% (1/89) for bile leak,3.4% (3/89) for chylous leak of grade B and C,11.2% (10/89) for abdominal infection,9.0% (8/89) for postoperative hemorrhage of grade B and C,4.5% (4/89) for delayed gastric emptying,6.7% (6/89) for deep vein thrombosis,3.4% (3/89) for reoperation,4.5% (4/89)for hospital mortality,7.9% (7/89) for 90-day mortality. The pathological type was pancreatic cancer for all 89 cases and pancreatic ductal adenocarcinoma made up 92.1% (82/89). The tumor size was 4.8(2.0) cm, ranging from 1.5 to 12.0 cm. The number of lymph nodes harvested was 14 (13)(range:2 to 33),with a positive lymph node rate of 13.0% (24.0%). The resection R0 rate was 30.0% (24/80) and the R1 (<1 mm) rate was 58.8% (47/80). The median overall survival time was 21.3 months (95%CI: 15.6 to 24.3) and the median disease-free survival time was 19.1 months (95%CI: 11.7 to 25.1). The overall survival at 1-year and 2-year were 69.60% and 39.52%. The median survival time of 58 patients with adjuvant chemotherapy was 24.3 months (95%CI: 17.8 to 32.3) while that of 13 patients without any kind of adjuvant therapy was 8.4 months (95%CI: 7.3 to 22.3). Seven patients accepted neoadjuvant chemotherapy and there was no significant morbidity among them,with a resection rate of R0 of 5/7. Conclusion: DP-CAR is safe and feasible for selective cases,which could be more valuable in improving long-term survival when combined with (neo) adjuvant therapy.

Crown ether-based anion exchange membranes with highly efficient dual ion conducting pathways.

Anion exchange membranes (AEMs) are a crucial constituent for alkaline fuel cells. As the core component of fuel cells, the low performance AEMs restrict the development and application of the fuel cells. Herein, the trade-off between the OH- conductivity and dimensional stability was solved by constructing AEMs with adequate OH- conductivity and satisfactory alkali resistance using Tröger's base (TB) poly (crown ether)s (PCEs) as the main chain, the embedded quaternary ammonium (QA) and Na+-functionalized crown ether units as the cationic group. Crown ether is an electron donator, and can capture Na+ to form Na+-functionalized crown ether units to conveniently transfer OH- and significantly promote the alkaline stability of the AEMs. The influence of the Na+-functionalized crown ether units on the performance of AEMs was studied in detail. The PCEs based AEMs show an obvious hydrophobic-hydrophilic microphase separation. These features make them ideal platforms for the OH- conduction applications. As expected, the as-prepared PCEs-QA-100% (100% is the degree of cross-linking) AEM with an ionic exchange capacity (IEC) of 2.07 meq g-1 has a high OH- conductivity of 159 mS cm-1 at 80 °C. Furthermore, the membrane electrode assemblies fabricated using the PCEs-QA-100% AEM possess a maximum power density of 291 mW cm-2 under the current density of 500 mA cm-2.

[Comparison of radical antegrade modular pancreatosplenectomy with conventional distal pancreatectomy for pancreatic adenocarcinoma of the body and tail].

Objective: To compare the short-term outcomes and long-term survivals of radical antegrade modular pancreatosplenectomy(RAMPS) and conventional distal pancreatectomy(CDP). Methods: A total of consecutive 304 patients including 176 male patients and 128 female patients who underwent RAMPS or CDP at Pancreas Center, the First Affiliated Hospital with Nanjing Medical University from May 2013 to June 2019 were retrospectively analyzed. The median age was 64.1 years old (range:39 to 85 years old). There were 101 patients underwent RAMPS and 203 patients underwent CDP. Measurement data with skewed distribution were presented as (M(Q(R))) and comparison between groups was evaluated with the Wilcoxon rank sum test. Count data were analyzed using the χ(2) test or Fisher exact probability. Survival analyses were performed by the Kaplan-Meier method after a one to one propensity score matching(PSM) conducted to balance several variables. Results: An eighty-one to eighty-one patients were enrolled after PSM. The overall morbidity was 32.1%(26/81)and there were no in-hospital mortalities in RAMPS. The median operative time was 225(95)minutes in RAMPS, not significantly longer as compared with CDP(210(130)minutes, P=0.916). The median greatest tumor diameter in RAMPS was 4.0(2.3)cm, not significantly larger as compared with CDP(4.5(2.2)cm, P=0.520).There were 34.6%(28/81)patients who presented with T4 tumors by 8(th) AJCC TNM staging system in RAMPS, which was not significantly different as compared with CDP(39.5%, χ(2)=0.574, P=0.902). The median number of examined lymph nodes was 9(9), not significantly greater in RAMPS as compared with CDP(10(11), P=0.992). The rate of negative posterior margins using 1 mm rule in RAMPS was 70.3%(52/74), significantly higher as compared with CDP(53.6%(30/56), χ(2)=3.817, P=0.044). The overall R0 resection rate was 44.6% (33/74) in RAMPS and 37.5% (21/56) in CDP, which was not significantly different(χ(2)=0.663, P=0.474). The median overall survival was 16.5 months for RAMPS, 25.2 months for CDP, and there was no statistical difference between two groups(P=0.981). The median overall survival was 16.0 months for patients with preoperative CA19-9≥300 U/ml who underwent RAMPS, 10.1 months for patients who underwent CDP, without significant difference(P=0.082). Conclusions: RAMPS can improve the rate of negative posterior margins by 1 mm rule and probably increase R0 resection rate and the harvest of lymph nodes. RAMPS may be beneficial to some patients with preoperative CA19-9≥300 U/ml.

[Hope and frustration of neoadjuvant chemotherapy for resectable pancreatic cancer].

There are many shortcomings in the existing strategy for the treatment of resectable pancreatic cancer by surgery combined with postoperative adjuvant chemotherapy.Neoadjuvant chemotherapy has the effects of clearing micrometastases, improving the margins, and assessing chemosensitivity of resectable pancreatic cancer.Currently, neoadjuvant chemotherapy is still mainly used for borderline resectable pancreatic cancer and unresectable pancreatic cancer.However, resectability assessment, patients selection, choice of chemotherapy regimens, assessment of chemotherapy response, chemotherapy cycles, and timing for surgery are still undetermined.At the same time, the mainstream regimens are highly toxic, expensive, and have a long course of treatment.It is still a small number of patients that can successfully pass the chemotherapy screening to undergo resection.It should be recognized that pancreatic cancer is still a chemotherapy-insensitive tumor.There are many unreasonable ways to use neoadjuvant chemotherapy in pancreatic cancer like chemotherapy-sensitive tumors.We need to explore more scientific, economical and applicable approaches for neoadjuvant chemotherapy on resectable pancreatic cancer.

[Analysis of risk factors and outcomes for delayed gastric emptying following pancreaticoduodenectomy: a single center experience of 492 cases].

Objective: To evaluate risk factors for delayed gastric emptying(DGE)following pancreaticoduodenectomy(PD). Methods: There were 492 consecutive patients who underwent PD in Pancreas Center, the First Affiliated Hospital with Nanjing Medical University between January 2012 and December 2014 were identified from a prospective database.There were 315 male and 177 female patients with a median age of 60.5 years.Univariate and multivariate analyses were performed to investigate the independent risk factors for clinically relevant DGE(CR-DGE). Results: The overall incidence of DGE was 29.5%, with Grade B and C occurring at 4.3% and 5.9%, respectively.In multivariate analysis, pancreatic duct diameter less than 3 mm(OR=1.888, P=0.042), pylorus-preserving pancreaticoduodenectomy(OR=2.627, P=0.005) and clinically relevant postoperative pancreatic fistula(OR=2.740, P=0.007) were independently associated with CR-DGE.Other main complications such as postoperative pancreatic fistula, pyoperitoneum, intraabdominal infection were also associated with the severity of DGE(χ(2)=21.360, 14.422, 14.378; P=0.011, 0.002, 0.002). DGE patients had a significantly prolonged postoperative length of stay(31(24-41)d vs. 13(11-17)d) and increased medical cost((122 367.5±66 068.3)yuan vs. (78 200.7±27 043.9)yuan)(both P<0.01). Conclusions: Small pancreatic duct, underwent pylorus-preserving pancreaticoduodenectomy and suffered postoperative pancreatic fistula might indicate a high risk of CR-DGE.

[Laparoscopic pancreaticoduodenectomy with a novel artery first and uncinate process first approach through Treitz ligament].

Objective: To explore the clinical effect of a novel artery first and uncinate process first approach for laparoscopic pancreaticoduodenectomy(LPD), emphasizing the left lateral and posterior dissection of uncinate process (UP) via Treitz ligament approach. Methods: From April to November 2016, 18 patients received LPD with a novel approach in Pancreas Center of the First Affiliated Hospital with Nanjing Medical University. All patients were diagnosed as pancreatic head or peri-ampulla tumor, without major vessel invasion nor distant metastasis. For resection, routine caudal view was used in the first step, to dissect the anterior medial border between uncinate process and superior mesenteric vein(SMV). Lymphatic tissues were completely dissected form anterior surface of hepatoduodenal ligament. In the second step, left lateral view with camera from left para-umbilical trocar was used, Treitz ligament was incised, SMA root was exposed. After anticlockwise rotation and retraction of mesentery, the anatomic relationship between SMA trunk, inferior pancreaticoduodenal artery(IPDA), jejunal branch of SMV, and distal part of UP, could be perfectly exposed from left lateral view. SMA was dissected from its root until the position above the uncinate process and duodenum, IPDA was transected, distal part of UP was freed from SMA. In the third step, right lateral view and caudal view were alternatively used; proximal UP mesentery was completely dissected out from SMA root, CA root and posterior surface of hepatoduodenal ligament. Pancreaticoduodenectomy was completed in the forth step after transection of pancreatic neck and common hepatic duct. Results: The SMA root and distal UP were successfully dissected out via Treitz ligament approach in all 18 patients, among them, distal UP was completely excised in 8 patients from left view. Postoperative pathology showed R0 resection rate in 69%. Postoperative complication included intra-abdominal hemorrhage in 1 patient, pancreatic fistula in 7 patients(6 cases with grade A and 1 case with grade B), delayed gastric emptying in 4 patients (2 cases with grade A, 2 cases with grade B). Average postoperative hospital stay was (15.5±6.8)days. Conclusion: The novel artery first and uncinate process first approach through Treitz ligament could help surgeons to completely dissect the full length of meso-pancreas along celiac axis-SMA axis in LPD.