Feasibility and efficacy of minimally invasive limited resection for primary duodenal gastrointestinal stromal tumors: a retrospective cohort study.

BACKGROUND: The primary duodenal gastrointestinal stromal tumor (GIST) is a rare type of gastrointestinal tract tumor. Limited resection (LR) has been increasingly performed for duodenal GIST. However, only a few studies reported minimally invasive limited resection (MI-LR) for primary duodenal GIST. METHODS: The clinical data of 33 patients with primary duodenal GIST from December 2014 to February 2024 were retrospectively analyzed including 23 who received MI-LR and 10 who received laparoscopic or robotic pancreaticoduodenectomy (LPD/RPD). RESULTS: A total of 33 patients with primary duodenal GIST were enrolled and retrospectively reviewed. Patients received MI-LR exhibited less OT (280 vs. 388.5min, P=0.004), EBL (100 vs. 450ml, P<0.001), and lower morbidity of postoperative complications (52.2% vs. 100%, P=0.013) than LPD/RPD. Patients received LPD/RPD burdened more aggressive tumors with larger size (P=0.047), higher classification (P<0.001), and more mitotic count/50 HPF(P=0.005) compared with patients received MI-LR. The oncological outcomes were similar in MI-LR group and LPD/RPD group. All the patients underwent MI-LR with no conversion, including 12 cases of LLR and 11 cases of RLR. All of the clinicopathological data of the patients were similar in both groups. The median OT was 280(210-480) min and 257(180-450) min, and the median EBL was 100(20-1000) mL and 100(20-200) mL in the LLR and the RLR group separately. The postoperative complications mainly included DGE (LLR 4 cases, 33.4% and RLR 4 cases, 36.4%), intestinal fistula (LLR 2 cases, 16.7%, and RLR 0 case), gastrointestinal hemorrhage (LLR 0 case and RLR 1 case, 9.1%), and intra-abdominal infection (LLR 3 cases, 25.0% and RLR 1 case, 9.1%). The median postoperative length of hospitalization was 19.5(7-46) days in the LLR group and 19(9-38) days in the RLR group. No anastomotic stenosis, local recurrence or distant metastasis was observed during the follow-up period in the two groups. CONCLUSIONS: Minimally invasive limited resection is an optional treatment for primary duodenal GIST with satisfactory short-term and long-term oncological outcomes.

Analysis of long-term outcomes after minimally invasive spleen-preserving distal pancreatectomy under the 'Kimura-first' strategy.

INTRODUCTION: Spleen-preserving distal pancreatectomy (SPDP) can be carried out by the Kimura technique (KT) or Warshaw technique (WT). This study aimed to evaluate the long-term post-operative outcomes of the two minimally invasive SPDP methods under the 'Kimura-first' strategy with a particular focus on the haemodynamic changes in the splenogastric circulation. PATIENTS AND METHODS: The electronic medical records and follow-up data of patients who underwent minimally invasive SPDP in our centre from March 2016 to July 2022 were reviewed. The haemodynamic changes in splenogastric circulation were monitored by post-operative computed tomography (CT) images, and the risks they caused were assessed by long-term follow-up. RESULTS: A total of 112 patients (KT = 93 and WT = 19) were included in the study. The tumour size in the WT group was significantly larger than that in the KT group ( P = 0.02). We also found less blood loss for patients who underwent KT ( P = 0.02). The occurrence of gastric varices was significantly higher in the WT group ( P = 0.022). There was no gastrointestinal bleeding in either group. There were two cases of splenic infarction in the WT group (11.1%), and the incidence was higher than that in the KT group ( P = 0.026). The infarct area gradually decreased during periodic CT examinations and disappeared completely at the last review. The two groups of patients had similar results across the 15 items in three areas of the quality of life questionnaire. CONCLUSIONS: The 'Kimura-first' strategy, in which the WT is used as an alternative to the KT when the splenic vessels cannot be safely preserved, is feasible, and safe for minimally invasive SPDP.

The CA125 level postoperative change rule and its prognostic significance in patients with resectable pancreatic cancer.

BACKGROUND: The relationship between postoperative CA125 level changes and early recurrence after curative resection of resectable PDAC is still unclear. METHODS: The electronic medical records and follow-up data of patients with resectable pancreatic cancer were evaluated. Dynamic CA125 detection was used to identify the rules for postoperative CA125 level change and its prognostic value in patients with resectable pancreatic cancer. RESULTS: The study included a total of 118 patients with resectable pancreatic cancer who underwent curative resection. Early postoperative CA125 levels were significantly higher than those before surgery (P < 0.05). It decreased gradually in the group without early recurrence (P < 0.05) but not in the early recurrence group (P>0.05). There was no correlation between early postoperative CA125 levels and early recurrence (P > 0.05). CA125 levels three months after surgery were associated with an increased risk of early recurrence (P = 0.038, 95% CI (1.001-1.025)). The cutoff CA125 level at 3 months after surgery for predicting early recurrence was 22.035. Patients with CA125 levels < 22.035 three months postoperatively had similar DFS and OS, regardless of whether the value was exceeded in the early postoperative period, but these values were significantly better than those of patients with CA125 levels > 22.035 at 3 months postoperatively (p < 0.05). CONCLUSIONS: Patients with different prognoses have different patterns of CA125 level changes. Elevations in CA125 levels > 3 months postoperatively, rather than early postoperative elevation, were associated with a poor prognosis.

Laparoscopic transabdominal preperitoneal repair for female patients with groin hernias.

BACKGROUND: Laparoscopic transabdominal preperitoneal repair (TAPP) was recommended for female patients with groin hernias. Whereas, only a few studies focused on whether and how to preserve the round ligament of the uterus in TAPP. METHODS: Clinical data of 159 female patients with 181 groin hernias who underwent TAPP at a single institution in China from January 2016 to June 2022 were retrospectively reviewed and collected. RESULTS: All the patients underwent the operation smoothly without conversion. Division of the round ligament was performed for 33 hernias. Preservation of the round ligament was adopted for 148 hernias, 51 with the "keyhole" technique, 86 with the "longitudinal incision of peritoneum" method, and 11 with total dissection of the round ligament. The mean operative time was 55.6 ± 8.7 min for unilateral TAPP and 99.1 ± 15.8 min for bilateral TAPP. The mean estimated blood loss was 7.1 ± 4.5 mL. The postoperative complications included 6 (3.3%) cases of seroma, 1 (0.5%) case of hematoma, and 3 (1.6%) cases of mild chronic pain. The incidences of chronic pelvic pain and genital prolapse seemed to be higher in the division group than in the preservation groups (6.1% vs. 0.6% and 3.0% vs. 0%, separately). However, no statistical difference was observed (p > 0.05). CONCLUSIONS: TAPP is feasible and effective for female patients with groin hernias, especially in preserving the round ligament of the uterus.

A randomized controlled trial evaluating effects of prophylactic irrigation-suction near pancreaticojejunostomy on postoperative pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common complication after pancreaticoduodenectomy (PD). However, whether irrigation-suction (IS) decreases the incidence and severity of CR-POPF has not yet been well elucidated. METHODS: One hundred and twenty patients with planned PD were enrolled in the study at a high-volume pancreatic center in China from August 2018 to January 2020. A randomized controlled trial (RCT) was conducted to evaluate whether irrigation-suction (IS) decreases the incidence and severity of CR-POPF and other postoperative complications after PD. The primary endpoint was the incidence of CR-POPF, and the secondary endpoints were other postoperative complications. RESULTS: Sixty patients were assigned to the control group and 60 patients to the IS group. The IS group had a comparable POPF rate (15.0% vs. 18.3%, p = 0.806) but a lower incidence of intra-abdominal infection (8.3% vs. 25.0%, p = 0.033) than the control group. The incidences of other postoperative complications were comparable in the two groups. The subgroup analysis for patients with intermediate/high risks for POPF also showed an equivalent POPF rate (17.0% vs. 20.4%, p = 0.800) and a significantly decreased incidence of intra-abdominal infection (8.5% vs. 27.8%, p = 0.020) in the IS group than that in the control group. The logistic regression models indicated that POPF was an independent risk factor for intra-abdominal infection (OR 0.049, 95% CI 0.013-0.182, p = 0.000). CONCLUSIONS: Irrigation-suction near pancreaticojejunostomy does not reduce the incidence or severity of postoperative pancreatic fistula but decreases the incidence of intra-abdominal infection after pancreaticoduodenectomy.

Effects of intraoperative fixation of residual hernia sac on postoperative seroma in laparoscopic transabdominal preperitoneal inguinal hernia repair: a prospective randomized controlled trial.

The study was aimed to evaluate a prospective randomized controlled trial (RCT) In laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP), whether fixation of the residual sac after transecting the hernia sac can reduce the severity of postoperative seroma. A total of 252 male patients with a primary unilateral indirect inguinal hernia who underwent TAPP from September 2018 to November 2022 were recruited. Patients were randomized to the control group (CG)and the experimental group (EG). In the experimental group, after the hernia sac was transected, the residual sac was fixed to the lower edge of the rectus abdominis, while it was left in the preperitoneal space in the control group. Close follow-up was arranged to observe the incidence of seroma and other postoperative complications. All 214 patients were discharged successfully. 106 patients were randomly assigned to the control group, and 108 patients were assigned to the experimental group. There was no significant difference in the incidence of postoperative fluid extraction between the experimental group and the control group (11.1% VS.10.4%, p = 0.862), but the patients with seroma after the operation had fewer repeated extraction (0% VS. 45.5%, P = 0.033). The incidences of other postoperative complications were comparable in the two groups. In the treatment of indirect inguinal hernia with TAPP, after transecting the hernia sac, suturing and fixing the residual sac to the inferior edge of the rectus abdominis can reduce the incidence of repeated aspiration.

Robotic parenchymal-sparing pancreatectomy and pancreas-sparing duodenectomy avoid pancreaticoduodenectomy for benign and low-grade malignant tumours.

BACKGROUND: Parenchymal-sparing pancreatectomy (PSP) or pancreas-sparing duodenectomy (PSD) is an alternative method for patients with benign or low-grade malignant tumours at the pancreatic head or duodenum. It avoids traumatic pancreaticoduodenectomy (PD) with pancreatic function preservation and improves quality of life. However, few studies have reported on robotic PSP (RPSP) or robotic PSD (RPSD). METHODS: A retrospective analysis of 17 patients with benign and low-grade malignant pancreatic head and duodenal tumours who underwent RPSP or RPSD from January 2018 to February 2022 was conducted. The demographic, perioperative, and postoperative data of all patients were collected and analysed. RESULTS: The operations were successful for all seventeen patients without conversion, including 10 cases of RPSP and 7 cases of RPSD. For RPSP, eight patients underwent pancreatic enucleation, and two patients underwent uncinate process resection. For RPSD, five patients underwent local duodenectomy, and two patients underwent segmental duodenectomy, with five simultaneous jejunostomies and two distal gastrectomies. The median OT and EBL were 135 min and 50 mL for RPSP and 220 min and 100 mL for RPSD, respectively. The median LOS was 8 days for RPSP and 19 days for RPSD. The main postoperative complications for RPSP included POPF (grade B, 6 cases), DGE (grade B, 1 case), PPH (1 case), and intra-abdominal infection (1 case). The main postoperative complications for RPSD included DGE (grade B, 1 case, grade C, 3 cases), postoperative haemorrhage (1 case), intra-abdominal infection (1 case), and duodenal fistula (1 case). One patient underwent interventional drain placement after RPSP because of POPF. CONCLUSION: RPSP or RPSD is feasible for highly selected patients with benign and low-grade malignant pancreatic head and duodenal tumours, avoiding potential pancreaticoduodenectomy.

Transabdominal preperitoneal repair for a recurrent inguinal hernia after Kugel procedure using the medial umbilical ligament: A case report.

The Kugel procedure resulted in extensive adhesion in the preperitoneal space. Performing a transabdominal preperitoneal repair (TAPP) for recurrent hernia after Kugel procedure is extremely difficult. In this case report, we present the case of a 81-year-old male who presented with recurrent inguinal hernia after Kugel procedure 8 years ago. Transabdominal laparoscopy was performed first. Indirect hernia formed inferior to the lateral edge of the previous mesh was diagnosed under laparoscopy. The patient's medial umbilical ligament (MUL) was big enough and could be completely released by separating the Retzius space. Finally, TAPP was successfully performed by using the MUL to create and close the preperitoneal space. No perioperative complications or hernia recurrence was observed 1 year after the surgery. Using the MUL to deal with preperitoneal problems was practical and feasible.

Effects of ribosomal associated protein hnRNP D in gemcitabine-resistant pancreatic cancer.

OBJECTIVE: To investigate the role of ribosomal associated protein hnRNP D in resistance to gemcitabine (GEM) in pancreatic cancer cells. METHODS: The expressions of hnRNP D in clinical pancreatic cancer tissues were detected by immunohistochemistry. The proliferation of pancreatic cancer cell lines (PANC-1, BXPC-3, SW1990 and ASPC-1) were measured by CCK8 assay. IC50 of each cell line was calculated and compared. The expressions of hnRNP D protein in pancreatic cancer cell lines were detected by Western Blot assay. The change of hnRNP D expression was confirmed by qPCR and Western Blot after the expressions of hnRNP D in PANC-1 cells being down-regulated by miRNA. And than the apoptosis rate and cell cycle of PANC-1 cells were detected by flow cytometry, while the expressions of apoptosis-related proteins cleaved caspase3, P-Akt, AKT and P65 were detected by Western Blot. RESULTS: HnRNP D protein expressed in clinical pancreatic tissues widely. The IC50 of GEM in PANC-1 was the highest while in BXPC-3 was the lowest. And the expression of hnRNP D protein in PANC-1 was the highest while in BXPC-3 was the lowest. After miRNA interfering, the expressions of hnRNP D protein and gene were significantly decreased in PANC-1 cells. The decrease of hnRNP D expression promoted cell apoptosis and inhibited the cell transformation to the S phase in cell cycle. Under the intervention of GEM, cleaved caspase3 expression was significantly increased, while p-Akt, AKT and P65 expression was significantly decreased. CONCLUSION: HnRNP D was associated with resistance to GEM in pancreatic cancer cells. Decreasing of hnRNP D expression promoted cell apoptosis induced by GEM.

Laparoscopic biopsy and staging for locally advanced pancreatic cancer: experiences of 76 consecutive patients in a single institution.

BACKGROUND: Pathological diagnosis plays a critical role in the treatment of locally advanced pancreatic cancer (LAPC). However, the commonly used biopsy methods still have a number of shortcomings, such as a relatively low diagnostic accuracy and a high incidence of complications. METHODS: A retrospective review was conducted to compare 76 patients with laparoscopic biopsy and staging and 11 patients with CT-guided pancreatic biopsy for LAPC between January 2017 and October 2020. Logistic regression with univariate and multivariate analyses was performed to identify preoperative predictors of occult metastasis. RESULTS: The diagnostic accuracy of laparoscopic biopsy and staging for pancreatic cancer was 100%. Sixty-two patients were confirmed to have LAPC, 59 patients by pancreatic biopsy and three patients by regional lymph node biopsy. Fourteen patients were diagnosed with distant occult metastasis, three patients by liver biopsy and 11 patients by peritoneum biopsy. Nine patients with severe obstructive manifestations underwent a simultaneous bypass procedure. No postoperative hemorrhage, pancreatic fistula, intra-abdominal infection, or trocar site metastasis was observed. Laparoscopic biopsy and staging had a higher diagnostic accuracy (100% vs. 81.8%, p=0.0147) and a shorter duration to chemotherapy (3 days vs. 9 days, p=0.035) than CT-guided biopsy. Elevated CA125 levels (≥35 U/ml) were a significant preoperative predictor of occult metastasis (OR 6.482, 95% CI 1.624-25.874, p=0.008). CONCLUSIONS: Laparoscopic biopsy and staging are safe and effective methods to obtain rapid pathology and precise staging for LAPC patients, especially for patients with elevated CA125 levels.

Perioperative outcomes of robotic pancreaticoduodenectomy: a single surgeon's experience with 55 consecutive cases.

BACKGROUND: Robotic pancreaticoduodenectomy (RPD) has been increasingly performed for patients with periampullary tumours and tumours in the pancreatic head. This method offers several technical advantages compared to open and laparoscopic surgeries. However, the surgical results often vary depending on the experience of different pancreatic centres. METHODS: A retrospective study of our first 55 cases of RPD from August 2016 to April 2020 was conducted to evaluate the perioperative outcomes of RPD and to summarize the operative experiences in a single intuition. Benign and malignant tumours in the pancreatic head or periampullary tumours without obvious vascular and adjacent organ invasion were included in this study. Perioperative characteristics and postoperative complications of the enrolled patients were retrospectively collected. RESULTS: The first 17 cases were robot-assisted laparoscopic pancreaticoduodenectomy (RA-LPD) and the remaining 38 patients underwent total RPD. The RA-LPD group had a remarkably longer operative time than the total RPD group (415.3±89.2 vs. 362.4±75.6 min, P=0.047). The incidences of biliary leakage, chyle leakage, DGE, intra-abdominal infection and intra-abdominal haemorrhage were 3.6%, 0.0%, 5.5%, 9.1% and 5.5%, respectively. Two patients underwent relaparotomy due to severe intra-abdominal haemorrhage. The median length of hospital stay was 14 (11 to 19) days. There were no deaths during the perioperative period. CONCLUSIONS: RPD is a technically feasible procedure for selected patients with periampullary tumours and tumours in the pancreatic head in experienced hands.

"Kimura-first" strategy for robotic spleen-preserving distal pancreatectomy: experiences from 61 consecutive cases in a single institution.

BACKGROUND: Robotic spleen-preserving distal pancreatectomy (RSPDP) is an ideal procedure for benign and low-grade malignant tumors in the distal pancreas, and two splenic preservation techniques (the Kimura and Warshaw techniques) can be used for RSPDP. This study aimed to evaluate the feasibility and safety of the "Kimura-first" strategy for RSPDP and to investigate the risk factors affecting the preservation of the spleen and splenic vessels. METHODS: The electronic medical records of patients who underwent robotic distal pancreatectomy (RDP) between October 2016 and December 2019 at our institution were retrospectively reviewed. Univariate and multivariate analyses were conducted to identify the risk factors influencing preservation of the spleen and splenic vessels during RDP. RESULTS: Sixty-one patients scheduled for RSPDP who received RDP were included in this study [Kimura technique, 41 patients; Warshaw technique, 11 patients; and robotic distal pancreatectomy with splenectomy (RDPS), 9 patients]. The overall splenic preservation rate with RDP was 85.2% (52/61). The preservation rate of splenic vessels with the Kimura technique with RSPDP was 78.8% (41/52). The RSPDP group had remarkably less estimated blood loss (EBL; median 50 vs. 300 mL, P=0.000) and a lower morbidity rate (13.5% vs. 44.4%, P=0.047) than the RDPS group. The logistic regression models showed that obvious splenic vessel compression by the tumor was an independent risk factor for splenic vessel preservation with RSPDP (OR 0.021, 95% CI: 0.002-0.271, P=0.003) and RDP (OR 0.019, 95% CI: 0.002-0.176, P=0.000). CONCLUSIONS: The "Kimura-first" strategy is feasible and safe for RSPDP, with high rates of splenic and splenic vessel preservation. Obvious splenic vessel compression by the tumor can be used as a predictor of splenic vessel preservation with planned RDP.

Drainage decreases the seroma incidence in laparoscopic transabdominal preperitoneal (TAPP) hernia repair for large inguinoscrotal hernias.

BACKGROUND: Seroma is a common and inevitable postoperative complication in transabdominal preperitoneal (TAPP) hernia repair, especially in patients with large inguinoscrotal hernias. However, studies have rarely reported drainage in TAPP for large inguinoscrotal hernias. METHODS: Sixty-five patients with 78 large indirect inguinoscrotal hernias who underwent TAPP procedure with drainage between September 2016 and December 2019 were enrolled in this study. 181 patients with Type Ⅲ indirect inguinal hernias (European Hernia Society (EHS) classification, hernia defect >3 cm) who underwent TAPP without drainage (no-drainage group) between January 2019 and December 2019 were included for a comparison. In the drainage group, a 12-Fr drainage tube was inserted into the distal hernia sac via the preperitoneal space to decrease the incidence of seroma. RESULTS: There was no conversion to open procedures in all the patients. The operative time (56.5 ± 8.4 VS 54.8 ± 9.6 min, unilateral; 95.8 ± 10.4 VS 92.1 ± 13.9 min, bilateral), blood loss (5.9 ± 1.9 VS 5.6 ± 1.7 mL), visual analogue scale score on postoperative day 1 (2.3 ± 0.5 VS 2.2 ± 0.5) and postoperative hospital stay (1.1 ± 0.3 VS 1.0 ± 0.2 days) in the drainage group were equivalent to those in the no-drainage group (p > 0.05). The mean length of drainage was 5.2 ± 1.3 days. The drainage group had a significantly lower incidence of seroma than the no-drainage group (1.5% VS 9.4%, p = 0.037). The postoperative complications including haematoma, recurrence and chronic pain were comparable in the two groups. CONCLUSION: Drainage with appropriate duration is a feasible, safe and effective measure to decrease the incidence of seroma in TAPP for patients with large inguinoscrotal hernias.

Combination of anterior superior mesenteric vein-first and right posterior superior mesenteric artery-first approaches for uncinate process dissection in minimally invasive pancreaticoduodenectomy.

BACKGROUND: Uncinate process dissection is a key step in minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic and robotic procedures, which increase the intraoperative blood loss and operative time and decrease the R0 resection rate if improperly handled. However, few studies have reported the operative skills in detail. METHODS: We performed uncinate process dissection using a combination of the anterior superior mesenteric vein (SMV)-first approach and the right posterior superior mesenteric artery (SMA)-first approach in MIPD for 138 patients with periampullary tumors between March 2017 and October 2019. The demographic and perioperative data of all the patients were collected to evaluate the efficacy of this method. RESULTS: All patients underwent an uneventful operation. An assistant incision was performed to separate extensive adhesion between the tumor and the SMV in 3 patients. The combined approach had a notably shorter operation time and resection time, less intraoperative blood loss and a shorter postoperative hospital stay than the traditional approach (P<0.05). There were no significant differences in conversion rate, numbers of harvested lymph node or postoperative complications, including postoperative pancreatic fistula, bile leakage, delayed gastric emptying, postoperative bleeding and reoperation between the two groups (P>0.05). There were no deaths during the perioperative period. CONCLUSIONS: The combination of the anterior SMV-first approach and the right posterior SMA-first approach is a safe and feasible technique for uncinate process dissection in MIPD.

Chemotherapeutic efficacy of cucurmosin for pancreatic cancer as an alternative of gemcitabine: a comparative metabolomic study.

BACKGROUND: As the preferred drug for single chemotherapeutic application in pancreatic cancer, gemcitabine often demonstrated low sensitivity and strong chemotherapy resistance in patients. Therefore, the search for other drugs with high efficiency and low side effects has become of high importance. The aim of this study was to assess the therapeutic effects of cucurmosin on pancreatic cancer as an alternative of gemcitabine and explore its underlying biochemical mechanism. METHODS: The subcutaneous xenograft mice with pancreatic cancer were treated by high- and low-dose cucurmosin and gemcitabine, respectively. A comparative metabolomic analysis was performed on the serum samples from the different groups by 1H nuclear magnetic resonance (NMR) techniques and then subjected to univariate and multivariate statistical analysis. RESULTS: Cucurmosin demonstrated a dose-dependent inhibition to the pancreatic tumors. High-dose cucurmosin provided similar chemotherapeutic efficacy with gemcitabine by positively regulating pyruvate metabolism, glycolysis or gluconeogenesis, and cysteine and methionine metabolism. Inactivating GFR signaling pathway and further inducing apoptosis of tumor cells are the important mechanism of anti-tumor function of cucurmosin. CONCLUSIONS: Cucurmosin is a promising chemotherapeutic drug for pancreatic cancer. However, the dose selection and surface modification should be optimized according to the stage of pancreatic cancer, and an expanded study in both laboratory and clinical regimes needs to be performed.

Chemotherapy-based split stereotactic body radiation therapy for borderline resectable and locally advanced pancreatic cancer: study protocol of a prospective, single-arm phase II trial.

INTRODUCTION: The question of how to administer adequate chemotherapy to synchronise stereotactic body radiation therapy (SBRT) treatment strategy to maximise the benefits of neoadjuvant therapy for the improved prognosis of patients with borderline resectable (BRPC) and locally advanced (LAPC) pancreatic cancer is a challenging and debatable issue. No studies have yet evaluated the efficacy of split-course SBRT as the neoadjuvant chemoradiotherapy regimen. We aimed to study whether neoadjuvant chemotherapy plus split-course SBRT results in better outcomes in BRPC and LAPC patients. METHODS AND ANALYSIS: Treatment-naïve patients with radiographically confirmed BRPC or LAPC, supporting biopsy results and no severe comorbidities will be enrolled. They will be treated with nab-paclitaxel plus gemcitabine (nab-P+Gem) chemotherapy plus split-course SBRT, followed by an investigator's choice of continuation of treatment with nab-P+Gem or surgery. nab-P+Gem chemotherapy will commence on day 1 for each of six cycles: nab-paclitaxel 125 mg/m2 intravenous infusion over approximately 30-45 min, followed by gemcitabine 1000 mg/m2 intravenous infusion over about 30 min on days 1 and 15 of each 28-day cycle. During the first and second cycles of chemotherapy, SBRT will be given as a single irradiation of 10 Gy four times (days 2 and 16 of each 28-day cycle). The primary endpoint is progression-free survival; while the secondary outcomes are the time to treatment failure, disease control rate, overall response rate, overall survival, R0 resection rate and incidence of adverse effects. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethics Committee of Xiehe Affiliated Hospital of Fujian Medical University (No. 2019YF015-01). Results from our study will be disseminated in international peer-reviewed journals. All study procedures were developed in order to assure data protection and confidentiality. TRIAL REGISTRATION NUMBER: NCT04289792.

Robotic resection for benign primary retroperitoneal tumors via the transperitoneal approach.

BACKGROUND: Surgical resection is the primary treatment for benign primary retroperitoneal tumors. However, only a few studies have reported robotic resection for retroperitoneal tumors due to the low morbidity rate, and only a small fraction of retroperitoneal tumors are eligible for minimally invasive operations. METHODS: A retrospective study enrolling 16 patients with benign primary retroperitoneal tumors between November 2016 and April 2020 was conducted to evaluate the efficacy of robotic resection for benign primary retroperitoneal tumors via the transperitoneal approach. Surgical skills were described in detail and operative experiences were summarized. RESULTS: The operations were uneventfully performed without conversion in all the patients. The median operation time was 135 (120-180) min, and the median estimated blood loss was 25 (20-60) mL. The median duration of diet restoration was 2 (1-2) days and the median length of postoperative hospital stay was 6 (4-7) days. No serious intraoperative or postoperative complications occurred during the perioperative period. CONCLUSIONS: Robotic resection via the transperitoneal approach is a feasible and safe procedure for highly selected patients with benign primary retroperitoneal tumors, with few postoperative complications and a rapid recovery.

Sublay repair for primary superior lumbar hernia with the Kugel patch.

BACKGROUND: A superior lumbar hernia is a posterior ventral hernia that is rarely encountered in the clinical setting. However, no standard operative strategy exists for superior lumbar hernia repair at present. METHODS: Twelve patients with primary superior lumbar hernia who underwent sublay repair via the retroperitoneal space with the Kugel patch between December 2008 and June 2019 were included in this study. The demographic, peri-operative and post-operative data of the patients were collected to analyse the effectiveness of this technique. RESULTS: All patients underwent an uneventful operation. The median operative time was 60 min, and the median blood loss was 35 mL. The median hernia defect area was 16 cm2 . Five medium-sized Kugel patches (11 cm × 14 cm) and seven large-sized Kugel patches (14 cm × 17 cm) were used for the repairs. The median visual analogue scale score on post-operative day 1 was 3. The median time to removal of drainage was 3 days. The median duration of the hospital stay was 3 days. No serious post-operative complications, including seroma, haematoma, incision or mesh infection, recurrence and chronic pain, occurred during the follow-up period. CONCLUSION: Sublay repair for primary superior lumbar hernia with the Kugel patch shows benefits including a reliable repair, minimal invasiveness and few post-operative complications.

Establishment of human pancreatic cancer gemcitabine­resistant cell line with ribonucleotide reductase overexpression.

A gemcitabine (GEM)-resistant human pancreatic cancer cell line (PANC-1RG7) was established in vitro by gradually increasing GEM concentrations and cloning cell cultures to develop a cellular model of acquired drug resistance studies. We found that PANC-1RG7 cells exhibited significantly different morphological characteristics from parental cells. PANC-1RG7 cells grew slowly (p<0.05), yet the cell cycle remained unchanged (p>0.05). PANC-1RG7, with a resistance index to GEM of 39.9, showed cross-resistance characteristics to methotrexate, gefitinib, cisplatin and 5-fluorouracil. The proliferation inhibition of GEM was significantly reduced in vivo (p<0.05). The known resistance-associated genes and proteins we detected remained unchanged, with the exception of cytidine deaminase, multidrug resistance-related protein and breast cancer resistance protein genes, which decreased; by contrast, 5'-nucleotidase, ribonucleotide reductase (RRM) 1 and RRM2 proteins increased (p<0.05). Therefore, a cell line with acquired GEM resistance was established successfully. Resistance was acquired by overexpressing RRM1 and RRM2 proteins.

PANC-1 pancreatic cancer cell growth inhibited by cucurmosin alone and in combination with an epidermal growth factor receptor-targeted drug.

OBJECTIVES: To investigate the inhibition of PANC-1 pancreatic cancer cell growth by cucurmosin (CUS) and its possible mechanism. METHODS: We observed the inhibition of PANC-1 cell growth by sulforhodamine B and colony-forming experiments in vitro and established nonobese diabetic/severe combined immunodeficiency mouse subcutaneous tumor models in vivo. We used Western blot to analyze protein levels related to apoptosis and epidermal growth factor receptor (EGFR) signaling pathways after drug intervention, whereas the messenger RNA expression of EGFR was analyzed by quantitative real-time polymerase chain reaction. RESULTS: Sulforhodamine B and colony-forming experiments indicated that CUS inhibited PANC-1 cell proliferation in a dose- and time-dependent manner. A stronger inhibitory effect was observed when CUS was combined with gefitinib. The subcutaneous tumor growth was also inhibited. Western blot showed that all the examined proteins decreased, except for 4E-BP1 and the active fragments of caspase 3 and caspase 9 increased. Epidermal growth factor receptor expression did not change significantly in quantitative real-time polymerase chain reaction. CONCLUSIONS: Cucurmosin can strongly inhibit the growth of PANC-1 cells in vitro and in vivo. Cucurmosin can down-regulate EGFR protein expression, but not at the messenger RNA level. Cucurmosin can also inhibit the ras/raf and phosphatidylinositol 3-kinase/Akt downstream signaling pathways and enhance the sensitivity of the EGFR-targeted drug gefitinib.