Objective To investigate the value of diffusion weighted magnetie resonance imaging and apparent diffusion coefficient (ADC) value in the diagnosis of pancreatic cancer.MethodsThe clinical data of 36 patients with pancreatie cancer who were admitted to the Wuxi No.2 People's Hospital from March 2009 to June 2011 were retrospectively analyzed,and the clinical data of 30 healthy volunteers were collected.All candidates received diffusion weighted magnetie resonance imaging examination.The signal intensity ratios ( SIRs ) of the cancer and the pericancerous tissues in the T1 weighted-images (T1WI),T2 weighted-images (T2WI)and diffusion weighted-images (DWI) were compared by using one-way analysis of variance.The ADC values of the cancer and the paricancerous tissues were compared using the paired t test.The differences of the ADC values of the cancer and pericancerous tissues compared with those of healthy individuals were analyzed using an independent sample t test.ResultsThe accuracy rate of preoperative magnetic resonance imaging examination was 92％.The relative SIRs were 0.203 ± 0.190 in the T2 WI,0.399 ± 0.201 in the T1 WI and 0.579 ± 0.291 in the DWI,respectively,with no significant differences across the 3 kinds of images (F=5.92,6.15,6.83,P ＜ 0.05 ),while SIRs of the T1 WI and DWI were significantly higher than that of the T2 WI ( P ＜ 0.05 ).There was no significant difference in SIRs when comparing T1 WI and DWI ( P ＞ 0.05 ).The mean ADC values of the cancer and pericancerous tissues of the pancreatic cancer patients and the pancreatic tissues of healthy individuals were (1.40±0.24) ×10 3 mm2/s,(1.71 ±0.10) ×10-3 mm2/s and (1.73±0.30) ×10-3 mm2/s,respectively,with significant differences across the 3 modes of images (t =10.54,12.08,P ＜ 0.05).ConclusionDWI can show high quality images of the lesions,and ADC value is helpful in the diagnosis of pancreatic cancer.

Objective To study enhanced recovery after surgery (ERAS) in pancreaticoduodenectomy.Methods A case-control study was conducted on 56 patients who underwent pancreaticoduodenectomy in our hospital from May 2012 to December 2016.These patients were divided into two groups:25 patients received ERAS management (the ERAS group) and 31 patients traditional perioperative management (the control group).The data on postoperative pancreatic leakage,bile leakage,postoperative bleeding,delayed gastric emptying,postoperative intestinal function recovery,hospitalization stay,medical cost and readmission rate within 90 days between the two groups were compared.Results The rate of delayed gastric emptying,postoperative intestinal function recovery,hospitalization stay and medical cost were significantly better in the ERAS group than the control group (all P ＜ 0.05).There were no significant differences in the rates of pancreatic leakage,bile leakage,postoperative bleeding,and readmission within 90 days between the two groups (all P ＞ 0.05).Conclusions Perioperative ERAS in pancreaticoduodenectomy was safe and efficacious.It improved recovery of patients and reduced hospital stay and expenses.

To investigate the clinical characteristics,diagnosis and treatment of intrahepatic biliary cystadenoma,a total of 7 patients with intrahepatic biliary cystadenoma admitted in our department from January 2008 to June 2013 were enrolled and the clinical data (i.e.clinical manifestations,imaging features and surgical treatment) were analyzed retrospectively.All the 7 patients were female and diagnosed as intrahepatic biliary cystadenoma.Five cases complained right upper abdominal pain of various severities.Color Doppler ultrasound,CT and MRI confirmed the diagnosis in all patients.The surgery included irregular fight hepatectomy (n =2),left lateral lobe hepatectomy (n =3),and left hepatectomy (n =2).Patients with intrahepatic biliary cystadenoma usually manifest nonspecific clinical symptoms,and thus are prone to be misdiagnosed as simple hepatic cysts.For such patients,surgery is of first choice,and complete resection is the key to avoiding the recurrence and malignancy.

Objective To summarize the imaging features of computed tomography (CT)and magnetic resonance imaging (MRI) combined with multi-technology imaging and compare its effects in the preoperative evaluation of malignant perihilar biliary obstruction.Methods The clinical data of 20 patients receiving CT and MRI who were diagnosed with malignant perihilar biliary obstruction by pathological examination at the Wuxi Second People's Hospital between January 2008 and April 2014 were retrospectively analyzed.Patients receiving CT combined with negative-contrast CT cholangiopancreatography (nCTCP) and computed tomography angiography (CTA) were allocated into the CT group,and patients receiving MRI combined with magnetic resonance cholangiopancreatography (MRCP) and magnetic resonance angiography (MRA) were allocated into the MRI group.The images of the 2 groups were analyzed by 2 independent reviewers.The classification of malignant perihilar biliary obstruction,hepatic artery and portal vein invasions and lymph node and organ metastases were evaluated respectively,and then the results of evaluation were compared with the results of surgery and pathological examinations.The comparison between the accuracy of imaging examination in the 2 groups and accuracy of perihilar biliary obstruction classification were analyzed by the chi-square test.The comparison of evaluating accuracy (sensitivity and specificity) among vascular invasion and lymph node and organ metastases were done by the receiver operating characteristic (ROC) curve analysis,and the comparison of its accuracy were done by the z-score test.Results The imagings of bile duct involvement of the 2 groups showed that there were irregular thickening bile duct wall combined with retrograde intrahepatic bile duct dilatation.The symptoms of vascular invasion included the stricture and occlusion of blood vessels or more than half of vascular contact surface with tumor.The symptoms of lymph node metastasis included the enlarging short-axis or round-like circular enhanced lesions.The symptoms of organ involvement included the unclear boundary of lesions or low-density necrotic foci within organ.All the 20 patients underwent the surgical treatment,including 13 patients with hilar cholangiocarcinoma and 7 patients with gallbladder carcinoma.Hepatic artery invasions were detected in 5 patients,portal vein invasions in 10 patients,lymph node metastases in 10 patients and organ metastases in 4 patients.The cases of classification of perihilar biliary obstruction,hepatic artery invasion,portal vein invasion,lymph node metastasis and organ metastasis which were evaluated respectively by reviewer 1 and 2 were 18/18,19/18,18/18,17/16 and 18/19 in the CT group and 17/16,14/13,17/16,15/14 and 19/18 in the MRI group.The imaging of the 2 groups were compared with the evaluating accuracies of classification of malignant hilar biliary obstruction,hepatic artery and portal vein invasions,lymph node and organ metastases in the 2 groups,showing no significant differences (x2=12.593,8.889,z=1.823,1.956,0.462,0.817,0.977,0.751,0.233,1.403,P＞0.05).Conclusion CT and MRI for malignant hilar biliary obstruction had the same imaging features,meanwhile,they can provide an equivalent performance in the classification of malignant hilar biliary obstruction,hepatic artery and portal vein invasions and lymph node and organ metastases.

Objective:To investigate the clinical application value of computed tomography (CT) and magnetic resonance imaging (MRI) examination in preoperative evaluation of adjacent organ invasion for periampullary carcinomas (PACs).Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 81 patients with PACs who were admitted to the Affiliated Wuxi No.2 People′s Hospital of Nanjing Medical University from September 2013 to June 2019 were collected. There were 52 males and 29 females, aged from 41 to 80 years, with an average age of 62 years. Observation indicators: (1) surgical and pathological outcomes; (2) evaluation of adjacent organ invasion on CT and MRI examination for PACs; (3) comparison of diagnostic accuracy between CT and MRI examination in assessing adjacent organ invasion for PACs; (4) auxiliary and feature images of adjacent organ invasion for PACs; (5) comparison between CT and MRI examination in assessing adjacent organ invasion for PACs. Measurement data with skewed distribution were represented as M (range), and count data were described as absolute numbers or percentages. Comparison between groups was analyzed using the Mann-Whitney U test.The receiver operating characteristic curve and area under curve were used to evaluate diagnostic accuracy between CT and MRI examination in assessing adjacent organ invasion for PACs. Consistency was compared using the κ test. Results:(1) Surgical and pathological outcomes: of the 81 patients, 76 underwent pancreatoduodenectomy, 5 underwent palliative gastrojejunostomy or biliary drainage combined with biopsy, including the pancreas, duodenum, or lymph nodes. Of the 81 patients, 35 had pancreatic head carcinoma including 26 with duodenal invasion and 9 without duodenal invasion; 23 had ampullary carcinoma including 17 with duodenal invasion, 4 with both duodenal invasion and pancreatic invasion, and 2 without duodenal invasion or pancreatic invasion; 17 had distal bile duct carcinoma (including papillary type in 4 patients and periductal infiltrative type in 13 patients), of which 8 had duodenal invasion, 1 had duodenal invasion and pancreatic invasion (pathological classification of the 9 patients was periductal infiltrative type), 8 had neither duodenal invasion nor pancreatic invasion; 6 had duodenal carcinoma including 4 with pancreatic invasion and 2 without pancreatic invasion. (2) Evaluation of adjacent organ invasion on CT and MRI examination for PACs: of the 35 patients with pancreatic head carcinoma, duodenal invasion was identified in 25 patients and no duodenal invasion in 10 patients on both CT and MRI examination. Of the 23 patients with ampullary carcinoma, duodenal invasion, pancreatic invasion, both duodenal invasion and pancreatic invasion, and neither duodenal invasion nor pancreatic invasion were identified in 17, 1, 4, and 1 patients on CT examination, respectively; the above indicators were identified in 15, 2, 4, and 2 patients on MRI examination. Of the 17 patients with distal bile duct carcinoma, pancreatic invasion, both duodenal invasion and pancreatic invasion, and neither duodenal invasion nor pancreatic invasion were identified in 8, 1, and 8 patients on CT examination, respectively; the above indicators were identified in 9, 1, and 7 patients on MRI examination. Of the 6 patients with duodenal carcinoma, pancreatic invasion and no pancreatic invasion were identified in 3 and 3 patients on both CT and MRI examination.(3) Comparison of diagnostic accuracy between CT and MRI examination in assessing adjacent organ invasion for PACs: two reviewers had good agreement in assessing adjacent organ invasion on CT examination for pancreatic head carcinoma, ampullary carcinoma, and distal bile duct carcinoma ( κ=0.868, 0.701, 0.881, P<0.05), but they had poor agreement for duodenal carcinoma ( κ=0.333, P>0.05). Meanwhile, two reviewers had good agreement in assessing adjacent organ invasion on MRI examination for pancreatic head carcinoma and ampullary carcinoma( κ=0.860, 0.747, P<0.05), and moderate agreement for distal bile duct carcinoma ( κ=0.643, P<0.05), but they had poor agreement for duodenal carcinoma ( κ=0.333, P>0.05). (4) Auxiliary and feature images of adjacent organ invasion for PACs: for the 25 patients who had pancreatic head carcinoma with duodenal invasion on CT and MRI examination, based on well filling in duodenum, 12 patients showed locally morphological change of lumen and flattened or disappeared duodenal mucosal folds on negative contrast CT cholangiopancreatography; 14 patients showed similar signs on T2 weighted imaging or magnetic resonance cholangiopancreatography. The 17 patients who had distal bile duct carcinoma with pancreatic invasion on CT and MRI examination were periductal infiltrative type. Pancreatic invasion manifested as local thickenness of ductal wall with marked enhancement and narrowed ductal lumen, which was indistinguishable from the pancreas, and the pancreatic parenchyma showed hyperdense or hyperintense signs similar with the lesion, like a "transmural" sign. One patient with both duodenal invasion and pancreatic invasion showed locally thickened and enhanced duodenal wall on both CT and MRI examination. Four patients, who had papillary type distal bile duct carcinoma with neither duodenal invasion nor pancreatic invasion, showed intraductal growing mass which had a discernible boundary to the pancreas and slighter enhancement than infiltrative type on both CT and MRI examination. (5) Comparison between CT and MRI examination in assessing adjacent organ invasion for PACs: CT examination evaluating adjacent organ invasion for pancreatic head carcinoma, ampullary carcinoma, distal bile duct carcinoma, and duodenal carcinoma had a sensibility of 92.3%, 90.5%, 88.9%, 75.0%, a specificity of 88.9%, 50.0%, 87.5%, 100.0%, an accuracy of 0.906, 0.702, 0.882, 0.875, respectively. MRI examination evaluating adjacent organ invasion for pancreatic head carcinoma, ampullary carcinoma, distal bile duct carcinoma, and duodenal carcinoma had a sensibility of 88.5%, 85.7%, 88.9%, 75.0%, a specificity of 77.8%, 50.0%, 75.0%, 100.0%, an accuracy of 0.831, 0.679, 0.819, 0.875. There was no significant difference in sensibility for pancreatic head carcinoma, distal bile duct carcinoma, or duodenal carcinoma between CT and MRI examination( χ2=3.140, 0.141, 0.444, P>0.05), while there was a significant difference in sensibility for ampullary carcinoma ( χ2=13.263, P<0.05). There was no significant difference in specificity for pancreatic head carcinoma, ampullary carcinoma, or distal bile duct carcinoma between CT and MRI examination( χ2=0.321, 2.000, 3.429, P>0.05). There was no significant difference in accuracy for pancreatic head carcinoma, ampullary carcinoma, distal bile duct carcinoma, or duodenal carcinoma between CT and MRI examination( Z=0.967, 0.273, 0.559, 0.000, P>0.05). Conclusion:CT and MRI examination can be used for preoperative evaluation of adjacent organ invasion for periampullary carcinoma, with similar performance in specificity and accuracy, however, CT examination has a higher sensibility for ampullary carcinoma.

Objective:To compare CT with MRI on the accuracy in TNM staging of pancreatic ductal adenocarcinoma (PDAC) based on the 8th American Joint Committee on Cancer System and Pathological Staging.Methods:From October 2013 to October 2019, 105 patients who had pathologically confirmed PDAC treated at the Affiliated Wuxi No.2 People’s Hospital of Nanjing Medical University were retrospectively studied. Of 52 patients who met the inclusion criteria, there were 32 males and 20 females, with age ranging from 45 to 84 years (mean 66.1 years). Based on the 8th American Joint Committee on Cancer System and Pathological Staging, CT was compared with MRI in their accuracies in categorizing TNM and staging of PDAC.Results:Forty-three of 52 patients who underwent curative resection had a mean tumor size of (3.4±1.2) cm, compared with tumor sizes of (3.3±1.2) cm and (3.3±1.4) cm on CT and MRI, respectively. No significant differences were observed between gross pathological examination and CT ( P>0.05) or MRI ( P>0.05). The accuracy of T, N, and M categories on CT versus (vs) MRI was 97.7% (42/43) vs 97.7% (42/43), 79.1% (34/43) vs 76.7% (33/43), and 100% (9/9) vs 88.9% (8/9), respectively. No significant differences were observed between the two modalities ( P>0.05). The overall accuracy of PDAC staging on CT vs MRI was 82.7% (43/52) vs 76.9% (40/52), respectively. There was also no significant difference between the two modalities ( P>0.05). Conclusion:Both CT and MRI had similar accuracies in categorizing TNM and staging of PDAC. However, the accuracies of T and M stages were higher than that of the N stage for these two imaging modalities.

Objective:To investigate the epidemiological characteristics, diagnosis, treat-ment and prognosis of gallbladder cancer in China from 2010 to 2017.Methods:The single disease retrospective registration cohort study was conducted. Based on the concept of the real world study, the clinicopathological data, from multicenter retrospective clinical data database of gallbladder cancer of Chinese Research Group of Gallbladder Cancer (CRGGC), of 6 159 patients with gallbladder cancer who were admitted to 42 hospitals from January 2010 to December 2017 were collected. Observation indicators: (1) case resources; (2) age and sex distribution; (3) diagnosis; (4) surgical treatment and prognosis; (5) multimodality therapy and prognosis. The follow-up data of the 42 hospitals were collected and analyzed by the CRGGC. The main outcome indicator was the overall survival time from date of operation for surgical patients or date of diagnosis for non-surgical patients to the end of outcome event or the last follow-up. Measurement data with normal distribu-tion were represented as Mean±SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M( Q1, Q3) or M(range), and com-parison between groups was conducted using the U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test. Univariate analysis was performed using the Logistic forced regression model, and variables with P<0.1 in the univariate analysis were included for multivariate analysis. Multivariate analysis was performed using the Logistic stepwise regression model. The life table method was used to calculate survival rates and the Kaplan-Meier method was used to draw survival curves. Log-rank test was used for survival analysis. Results:(1) Case resources: of the 42 hospitals, there were 35 class A of tertiary hospitals and 7 class B of tertiary hospitals, 16 hospitals with high admission of gallbladder cancer and 26 hospitals with low admission of gallbladder cancer, respectively. Geographical distribution of the 42 hospitals: there were 9 hospitals in central China, 5 hospitals in northeast China, 22 hospitals in eastern China and 6 hospitals in western China. Geographical distribution of the 6 159 patients: there were 2 154 cases(34.973%) from central China, 705 cases(11.447%) from northeast China, 1 969 cases(31.969%) from eastern China and 1 331 cases(21.611%) from western China. The total average number of cases undergoing diagnosis and treatment in hospitals of the 6 159 patients was 18.3±4.5 per year, in which the average number of cases undergoing diagnosis and treatment in hospitals of 4 974 patients(80.760%) from hospitals with high admission of gallbladder cancer was 38.8±8.9 per year and the average number of cases undergoing diagnosis and treatment in hospitals of 1 185 patients(19.240%) from hospitals with low admission of gallbladder cancer was 5.7±1.9 per year. (2) Age and sex distribution: the age of 6 159 patients diagnosed as gallbladder cancer was 64(56,71) years, in which the age of 2 247 male patients(36.483%) diagnosed as gallbladder cancer was 64(58,71)years and the age of 3 912 female patients(63.517%) diagnosed as gallbladder cancer was 63(55,71)years. The sex ratio of female to male was 1.74:1. Of 6 159 patients, 3 886 cases(63.095%) were diagnosed as gallbladder cancer at 56 to 75 years old. There was a significant difference on age at diagnosis between male and female patients ( Z=-3.99, P<0.001). (3) Diagnosis: of 6 159 patients, 2 503 cases(40.640%) were initially diagnosed as gallbladder cancer and 3 656 cases(59.360%) were initially diagnosed as non-gallbladder cancer. There were 2 110 patients(34.259%) not undergoing surgical treatment, of which 200 cases(9.479%) were initially diagnosed as gallbladder cancer and 1 910 cases(90.521%) were initially diagnosed as non-gallbladder cancer. There were 4 049 patients(65.741%) undergoing surgical treatment, of which 2 303 cases(56.878%) were initially diagnosed as gallbladder cancer and 1 746 cases(43.122%) were initial diagnosed as non-gallbladder cancer. Of the 1 746 patients who were initially diagnosed as non-gallbladder cancer, there were 774 cases(19.116%) diagnosed as gallbladder cancer during operation and 972 cases(24.006%) diagnosed as gallbladder cancer after operation. Of 6 159 patients, there were 2 521 cases(40.932%), 2 335 cases(37.912%) and 1 114 cases(18.087%) undergoing ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) examination before initial diagnosis, respec-tively, and there were 3 259 cases(52.914%), 3 172 cases(51.502%) and 4 016 cases(65.205%) undergoing serum carcinoembryonic antigen, CA19-9 or CA125 examination before initially diagnosis, respectively. One patient may underwent multiple examinations. Results of univariate analysis showed that geographical distribution of hospitals (eastern China or western China), age ≥72 years, gallbladder cancer annual admission of hospitals, whether undergoing ultrasound, CT, MRI, serum carcinoembryonic antigen, CA19-9 or CA125 examination before initially diagnosis were related factors influencing initial diagnosis of gallbladder cancer patients ( odds ratio=1.45, 1.98, 0.69, 0.68, 2.43, 0.41, 1.63, 0.41, 0.39, 0.42, 95% confidence interval as 1.21-1.74, 1.64-2.40, 0.59-0.80, 0.60-0.78, 2.19-2.70, 0.37-0.45, 1.43-1.86, 0.37-0.45, 0.35-0.43, 0.38-0.47, P<0.05). Results of multivariate analysis showed that geographical distribution of hospitals (eastern China or western China), sex, age ≥72 years, gallbladder cancer annual admission of hospitals and cases undergoing ultrasound, CT, serum CA19-9 examination before initially diagnosis were indepen-dent influencing factors influencing initial diagnosis of gallbladder cancer patients ( odds ratio=1.36, 1.42, 0.89, 0.67, 1.85, 1.56, 1.57, 0.39, 95% confidence interval as 1.13-1.64, 1.16-1.73, 0.79-0.99, 0.57-0.78, 1.60-2.14, 1.38-1.77, 1.38-1.79, 0.35-0.43, P<0.05). (4) Surgical treatment and prognosis. Of the 4 049 patients undergoing surgical treatment, there were 2 447 cases(60.435%) with complete pathological staging data and follow-up data. Cases with pathological staging as stage 0, stage Ⅰ, stage Ⅱ, stage Ⅲa, stage Ⅲb, stage Ⅳa and stage Ⅳb were 85(3.474%), 201(8.214%), 71(2.902%), 890(36.371%), 382(15.611%), 33(1.348%) and 785(32.080%), respectively. The median follow-up time and median postoperative overall survival time of the 2 447 cases were 55.75 months (95% confidence interval as 52.78-58.35) and 23.46 months (95% confidence interval as 21.23-25.71), respectively. There was a significant difference in the overall survival between cases with pathological staging as stage 0, stage Ⅰ, stage Ⅱ, stage Ⅲa, stage Ⅲb, stage Ⅳa and stage Ⅳb ( χ2=512.47, P<0.001). Of the 4 049 patients undergoing surgical treatment, there were 2 988 cases(73.796%) with resectable tumor, 177 cases(4.371%) with unresectable tumor and 884 cases(21.833%) with tumor unassessable for resectabi-lity. Of the 2 988 cases with resectable tumor, there were 2 036 cases(68.139%) undergoing radical resection, 504 cases(16.867%) undergoing non-radical resection and 448 cases(14.994%) with operation unassessable for curative effect. Of the 2 447 cases with complete pathological staging data and follow-up data who underwent surgical treatment, there were 53 cases(2.166%) with unresectable tumor, 300 cases(12.260%) with resectable tumor and receiving non-radical resection, 1 441 cases(58.888%) with resectable tumor and receiving radical resection, 653 cases(26.686%) with resectable tumor and receiving operation unassessable for curative effect. There were 733 cases not undergoing surgical treatment with complete pathological staging data and follow-up data. There was a significant difference in the overall survival between cases not undergoing surgical treatment, cases undergoing surgical treatment for unresectable tumor, cases undergoing non-radical resection for resectable tumor and cases undergoing radical resection for resectable tumor ( χ2=121.04, P<0.001). (5) Multimodality therapy and prognosis: of 6 159 patients, there were 541 cases(8.784%) under-going postoperative adjuvant chemotherapy and advanced chemotherapy, 76 cases(1.234%) under-going radiotherapy. There were 1 170 advanced gallbladder cancer (pathological staging ≥stage Ⅲa) patients undergoing radical resection, including 126 cases(10.769%) with post-operative adjuvant chemotherapy and 1 044 cases(89.231%) without postoperative adjuvant chemo-therapy. There was no significant difference in the overall survival between cases with post-operative adjuvant chemotherapy and cases without postoperative adjuvant chemotherapy ( χ2=0.23, P=0.629). There were 658 patients with pathological staging as stage Ⅲa who underwent radical resection, including 66 cases(10.030%) with postoperative adjuvant chemotherapy and 592 cases(89.970%) without postoperative adjuvant chemotherapy. There was no significant difference in the overall survival between cases with postoperative adjuvant chemotherapy and cases without postoperative adjuvant chemotherapy ( χ2=0.05, P=0.817). There were 512 patients with pathological staging ≥stage Ⅲb who underwent radical resection, including 60 cases(11.719%) with postoperative adjuvant chemotherapy and 452 cases(88.281%) without postoperative adjuvant chemotherapy. There was no significant difference in the overall survival between cases with postoperative adjuvant chemo-therapy and cases without post-operative adjuvant chemo-therapy ( χ2=1.50, P=0.220). Conclusions:There are more women than men with gallbladder cancer in China and more than half of patients are diagnosed at the age of 56 to 75 years. Cases undergoing ultrasound, CT, serum CA19-9 examination before initial diagnosis are independent influencing factors influencing initial diagnosis of gallbladder cancer patients. Preoperative resectability evaluation can improve the therapy strategy and patient prognosis. Adjuvant chemotherapy for gallbladder cancer is not standardized and in low proportion in China.