In recent years, great progress has been made in the diagnosis and treatment of pancreatic tumors. In terms of diagnosis, three-dimensional CT reconstruction, PET-CT scan, endoscopic ultrasound with needle biopsy are used to evaluate the benign or malignant stage and biological characteristics of the tumor, to make treatment decisions more scientific and reasonable. In terms of treatment, new technologies, such as arterial priority arterial sheath dissection and radical resection of the retroperitoneal lipo-lymphatic layer, have continuously emerged to improve radical curability of tumors. For benign or low-grade malignant pancreatic tumors, function-preserving surgery is adopted to avoid long-term complications. Minimally invasive pancreatic surgery has advanced in leaps and bounds. Both standard radical surgery and function-preserve surgery can be performed under a laparoscope or robot. Non-surgical treatment has developed quickly with each passing day; for locally advanced or metastatic pancreatic cancer, neoadjuvant therapy is expected to be down-staged or transformed into surgery. These advances in diagnosis and treatment technology have led to multidisciplinary teamwork. Based on accurate assessment, giving full play to the advantages of laparoscopic and robotic systems in diagnosis and treatment, attaching importance to comprehensive nonsurgical treatment and doctor-patient communication with care throughout the process, these are keys to improve the clinical efficacy of pancreatic tumors in the era of minimally invasive surgery.

Objective:To summarize the experience of robot-assisted enucleation of tumors located in uncinate process of pancreas.Methods:This is a retrospective case series study. The clinical data of patients with robot-assisted enucleation of tumors located in the uncinate process of pancreas at the Department of Gastroenterology and Pancreatic Surgery,Zhejiang Provincial People′s Hospital from June 2019 to December 2023 were retrospectively analyzed. A total of 16 cases were enrolled,including 10 males and 6 females,with an age( M(IQR)) of 56(21)years (range: 28 to 77 years),and body mass index of 22.4(2.3)kg/m 2 (range:19.8 to 25.6 kg/m 2). Follow-up was asked every 6 to 12 months after the first 3-month postoperative follow-up through out-patient service or via telephone. Results:In total 16 cases,there were 11 cases with pancreatic enucleation,and 5 cases with resection of the uninate process. The operation time was 70(60) minutes (range: 40 to 165 minutes),and the blood loss was 30(13)ml (range: 10 to 80 ml). The rate of pancreatic fistula was 5/16. The length of stay was 8(6)days (range: 5 to 33 days). The pathological finding included non-functional neuroendocrine tumor( n=3),insulinoma( n=2),introductal papillary mucinous neoplasm ( n=5),solid pseudopapillary neoplasm ( n=2),mucinous cystadenoma ( n=1),serous cystadenoma ( n=2),pseudocyst ( n=1). Follow-up as of March 12, 2024, the follow-up time was 16(12)months (range: 3 to 41 months). All patients had no new onset diabetes and no dyspepsia. Conclusion:Robot-assisted surgical system can be used for local resection of uncinate process tumors of pancreas,and the quality of life of patients can be improved.

Objective To investigate the role of delta/notch-like epidermal growth factor-related receptor(DNER)in gastric cancer and its regulatory mechanism.Methods The mRNA and protein levels of DNER in gastric cancer tissues and cells were detected with quantitative real time polymerase chain reaction(qRT-PCR)and Western blot.Gastric cancer cell line SGC7901 with silenced DNER expression was constructed,and cells were treated with mitochondrial dynamin-related protein 1(DRP1)inhibitor Mdivi-1.CCK-8 assay,Transwell assay,and flow cytometry were used to detect cell viability,invasion ability and apoptosis,respectively.Western blot was used to detect DNER protein levels,apoptosis-associated proteins[Cysteinyl aspartate-specific proteinase-3(Caspase-3),Bcl-2 Associated X(Bax)],autophagy associated proteins[microtubule-associated protein 1 light chain 3-Ⅱ/Ⅰ,LC3 Ⅱ/Ⅰ),p62,PTEN induced putative kinase 1(PINK1)and Parkin],and mitochondrial fission and fusion protein[DRP1,mitochondrial fission factor(MFF),mitochondrial fission protein 1(FIS1),Optic Atrophy 1(OPA1),mitofusin 1(MFN1)and MFN2]levels.Results The expression levels of DNER mRNA and protein in gastric cancer tissues were higher than those in adjacent normal tissues(t=-52.485,-46.955),while expression levels of DNER mRNA and protein in gastric cancer cells were higher than those in normal gastric epithelial cells(F=60.551,60.652),and the differences were significant(P＜0.001).Silencing DNER inhibited the proliferation and invasion of SGC7901 cells,induced apoptosis,and increased the expression of apoptosis-related proteins,with significant differences(t=8.026～25.903,all P＜0.05).Silenced DNER increased LC3 Ⅱ/Ⅰ ratio(t=18.086),decreased p62 protein level(t=6.747),promoted the aggregation of PINK1 and Parkin proteins in mitochondria(t=15.630,18.171),inhibited the expression of mitochondrial fusion proteins OPA1,MFN1 and MFN2(t=12.835,8.963,9.732),and promoted the expression of mitochondrial fission proteins DRP1,MFF and FIS1(t=16.034,16.939,15.971),with significant differences(all P＜0.05).Mdivi-1 treatment could counteract the effects of silencing DNER on mitochondrial autophagy,proliferation,invasion and apoptosis of gastric cancer cells.Conclusion DNER can reduce mitochondrial autophagy by inhibiting mitochondrial dynamic imbalance,promote cell proliferation and invasion,and inhibit cell apoptosis,thus promoting the progression of gastric cancer.

In recent years, great progress has been made in the diagnosis and treatment of pancreatic tumors. In terms of diagnosis, three-dimensional CT reconstruction, PET-CT scan, endoscopic ultrasound with needle biopsy are used to evaluate the benign or malignant stage and biological characteristics of the tumor, to make treatment decisions more scientific and reasonable. In terms of treatment, new technologies, such as arterial priority arterial sheath dissection and radical resection of the retroperitoneal lipo-lymphatic layer, have continuously emerged to improve radical curability of tumors. For benign or low-grade malignant pancreatic tumors, function-preserving surgery is adopted to avoid long-term complications. Minimally invasive pancreatic surgery has advanced in leaps and bounds. Both standard radical surgery and function-preserve surgery can be performed under a laparoscope or robot. Non-surgical treatment has developed quickly with each passing day; for locally advanced or metastatic pancreatic cancer, neoadjuvant therapy is expected to be down-staged or transformed into surgery. These advances in diagnosis and treatment technology have led to multidisciplinary teamwork. Based on accurate assessment, giving full play to the advantages of laparoscopic and robotic systems in diagnosis and treatment, attaching importance to comprehensive nonsurgical treatment and doctor-patient communication with care throughout the process, these are keys to improve the clinical efficacy of pancreatic tumors in the era of minimally invasive surgery.

Objective:To summarize the experience of robot-assisted enucleation of tumors located in uncinate process of pancreas.Methods:This is a retrospective case series study. The clinical data of patients with robot-assisted enucleation of tumors located in the uncinate process of pancreas at the Department of Gastroenterology and Pancreatic Surgery,Zhejiang Provincial People′s Hospital from June 2019 to December 2023 were retrospectively analyzed. A total of 16 cases were enrolled,including 10 males and 6 females,with an age( M(IQR)) of 56(21)years (range: 28 to 77 years),and body mass index of 22.4(2.3)kg/m 2 (range:19.8 to 25.6 kg/m 2). Follow-up was asked every 6 to 12 months after the first 3-month postoperative follow-up through out-patient service or via telephone. Results:In total 16 cases,there were 11 cases with pancreatic enucleation,and 5 cases with resection of the uninate process. The operation time was 70(60) minutes (range: 40 to 165 minutes),and the blood loss was 30(13)ml (range: 10 to 80 ml). The rate of pancreatic fistula was 5/16. The length of stay was 8(6)days (range: 5 to 33 days). The pathological finding included non-functional neuroendocrine tumor( n=3),insulinoma( n=2),introductal papillary mucinous neoplasm ( n=5),solid pseudopapillary neoplasm ( n=2),mucinous cystadenoma ( n=1),serous cystadenoma ( n=2),pseudocyst ( n=1). Follow-up as of March 12, 2024, the follow-up time was 16(12)months (range: 3 to 41 months). All patients had no new onset diabetes and no dyspepsia. Conclusion:Robot-assisted surgical system can be used for local resection of uncinate process tumors of pancreas,and the quality of life of patients can be improved.

Objective:To compare the perioperative outcomes between robotic pancreaticoduodenectomy(RPD)and laparoscopic pancreaticoduode-nectomy(LPD)in patients aged ≥65 years. Methods:The clinical data of 130 patients aged ≥65 years who received minimally invasive pancreaticoduodenectomy(MIPD)at Department of Gastrointestinal and Pancreatic Surgery,Zhejiang Provincial People's Hospital from January 2019 to December 2022 were retrospectively analyzed.The patients were divided into the RPD group(n=66)and the LPD group(n=64)according to the operation method,and the perioperative clinical data were compared between the 2 groups. Results:Compared with the LPD group,the average age of patients in the RPD group was higher than that of the LPD group[(71.95±4.73)years vs(70.39±3.9)years,P＜0.05];the RPD group had more patients with diabetes(39.4％vs 18.8％,P＜0.05)and cardiopulmonary diseases(37.9％vs 17.2％,P＜0.05);the RPD group had shorter operation time[(272.91± 68.38)min vs(362.81±78.24)min,P＜0.05]and less intraoperative blood loss[median(range):1 00 mL(50-200 mL)vs 1 50 mL(1 00-200 mL),P＜0.05)];the RPD group had higher incidence of chylous fistula(1 2.1％vs 1.6％,P＜0.05)but lower incidence of surgical morbidity(37.9％vs 46.9％),serious complications(19.7％vs 34.4％),postoperative pancreatic fistula(12.1％vs 17.2％),biliary fistula(3.0％vs 3.1％),abdominal infection(10.6％vs 14.1％),postoperative bleeding(4.5％vs 4.5％),and postoperative cardiopulmonary complications(1 2.1％vs 20.3％)with no statistically significant difference(P＞0.05);the RPD group waited shorter time before restarting diet[(3.97±1.59)d vs(5.34±2.56)d,P＜0.05]. Conclusion:MIPD is safe and feasible in patients aged ≥65 years.The incidence of perioperative complications is similar between the 2 groups.Compared with LPD,RPD has shorter operation time,less intraoperative blood loss,and shorter duration before restarting diet after operation,which has certain clinical advantages.

Objective:To summarize the characteristics and difficulties of minimal invasive surgery for adolescent with pancreatic head tumor.Methods:The data of adolescent younger than 28 years old with pancreatic head tumor treated at Department of Gastroenterology and Pancreatic Surgery, Zhejiang Province People′s Hospital from January 2014 to December 2019 were analyzed retrospectively. Fifteen cases were enrolled, included 5 males and 10 females. The median age was 20 years(range: 11 to 27 years) and the body mass index was (19.8±2.3)kg/m 2(range: 17.3 to 21.6 kg/m 2). Results:Standard pancreaticoduodenectomy was performed in 12 cases, including 9 cases of laparoscopic surgery and 3 cases of robotic-assisted surgery, and laparoscopic pancreaticoduodenectomy with resection of hepatic flexure of colon was performed on 1 case, and robotic-assisted duodenum-preserving pancreatic head resection with pancreatogastrostomy was performed on other 2 cases. The operative time was (269.0±65.1)minutes(range: 150 to 410 minutes), and the blood loss was (135.6±52.7)ml(range: 50 to 400 ml). Six patients got postoperative complications with gastrointestinal bleeding biochemical leakage and intestinal obstruction( n=1), pancreatic biochemical leakage( n=1), bile leakage( n=1), chylous leakage( n=1), wound infection( n=1), hepatic injury( n=1). The median postoperative hospital stay was 13 days(range: 9 to 22 days).The pathologic findings were solid pseudopapillary neoplasms( n=8), neuroendocrine neoplasms( n=3), introductal papillary mucinous neoplasm( n=1), cystic fibroma( n=1), serous cystadenoma( n=1), Ewing sarcoma( n=1).The median follow-up was 37 months(range: 2 to 75 months).The patient with Ewing sarcoma was diagnosed as liver metastasis at 41 months after surgery and died at 63 months after surgery.All the other patients survived without tumor.Three patients got the long-term complication of bile duct. Conclusions:Most of pancreatic head tumors for adolescent are benign or low malignant. Minimally invasive surgery be the first choice, and function-preserving surgery should be taken into account as much as possible.Perioperative management and communication is essential as the parents pay much attention to the quality of life after surgery.

Objective:To summarize the characteristics and difficulties of minimal invasive surgery for adolescent with pancreatic head tumor.Methods:The data of adolescent younger than 28 years old with pancreatic head tumor treated at Department of Gastroenterology and Pancreatic Surgery, Zhejiang Province People′s Hospital from January 2014 to December 2019 were analyzed retrospectively. Fifteen cases were enrolled, included 5 males and 10 females. The median age was 20 years(range: 11 to 27 years) and the body mass index was (19.8±2.3)kg/m 2(range: 17.3 to 21.6 kg/m 2). Results:Standard pancreaticoduodenectomy was performed in 12 cases, including 9 cases of laparoscopic surgery and 3 cases of robotic-assisted surgery, and laparoscopic pancreaticoduodenectomy with resection of hepatic flexure of colon was performed on 1 case, and robotic-assisted duodenum-preserving pancreatic head resection with pancreatogastrostomy was performed on other 2 cases. The operative time was (269.0±65.1)minutes(range: 150 to 410 minutes), and the blood loss was (135.6±52.7)ml(range: 50 to 400 ml). Six patients got postoperative complications with gastrointestinal bleeding biochemical leakage and intestinal obstruction( n=1), pancreatic biochemical leakage( n=1), bile leakage( n=1), chylous leakage( n=1), wound infection( n=1), hepatic injury( n=1). The median postoperative hospital stay was 13 days(range: 9 to 22 days).The pathologic findings were solid pseudopapillary neoplasms( n=8), neuroendocrine neoplasms( n=3), introductal papillary mucinous neoplasm( n=1), cystic fibroma( n=1), serous cystadenoma( n=1), Ewing sarcoma( n=1).The median follow-up was 37 months(range: 2 to 75 months).The patient with Ewing sarcoma was diagnosed as liver metastasis at 41 months after surgery and died at 63 months after surgery.All the other patients survived without tumor.Three patients got the long-term complication of bile duct. Conclusions:Most of pancreatic head tumors for adolescent are benign or low malignant. Minimally invasive surgery be the first choice, and function-preserving surgery should be taken into account as much as possible.Perioperative management and communication is essential as the parents pay much attention to the quality of life after surgery.

Objective: To summarize the incidence and characteristics of postoperative complications after laparoscopic pancreaticoduodenectomy(LPD), and to share our experience on management of complications. Methods: The clinical data of 320 LPD performed by a single team in Sir Run Run Shaw Hospital and Zhejiang Provincial People′s Hospital between September 2012 and September 2017 were retrospectively analyzed, among which there were 196 males and 124 females with age of (60.2±11.6) years old.There were 306 patients who underwent standard LPD, and 14 patients who underwent extended LPD. The patients were divided into 2 groups of former 160 LPD and later 160 LPD according to the time order. By analyzing the differences of clinical outcomes between the two groups, especially focusing on the incidence of postoperative complications.The experience on management of complications was concluded. The prior surgical history of latter group was significantly higher than the former group(30.0%(48/160)vs. 18.8%(30/160), χ²=5.49, P=0.019), and the rest of baseline characteristics remained the comparable (P>0.05). For resectable lesions, LPD was performed by "No back" approach, following the principle of "From distal to cephalad, from ventral to dorsal, and from left to right" . As for the borderline resectable patients, LPD was performed by "Easy first" strategy. Student t test, χ² test or Fisher test was used to analyzed the data between the two groups respectively. Results: Of 320 LPD patients, 306 cases underwent standard LPD, 14 cases underwent LPD with resection of other organs.There were 278 LPD cases who followed "No back" approach, and 42 cases who followed "Easy first" strategy because of difficulty in creating the retro-pancreatic tunnel. And the overall morbidity was 32.2%(103/320) with reoperation rate of 5.3%(17/320). The perioperative mortality was 0.6%(2/320). The operation time of latter group was ((346.6±48.8)minutes), which was shorter than that of former group((358.0±54.4)minutes)(t=1.97, P=0.048). The blood loss of former and latter group remained comparable((207.9±135.8)ml vs.(189.6±121.4)ml, P=0.205). However, in subgroup analysis, the patients with blood loss less <200 ml of latter group decreased significantly from 59.4%(95/160) to 47.5%(76/160)(χ²=4.53, P=0.033). The overall morbidity of latter group was 28.8%(46/160), indicated a decrease from 35.6%(57/160) of former group without significant difference(P=0.188). Moreover, Grade A/B/C pancreatic fistula rate, Grade A/C bile leakage rate, Grade B/C postoperative hemorrhage rate of the later group tended to decrease, although they also didn′t reach a significant difference. However, the abdominal infection rate decreased significantly(χ²=3.93, P=0.047). The length of hospital stay remained comparable(P=0.156). Conclusions The most common complications after LPD were postoperative hemorrhage and pancreatic fistula. With specialized team and accumulated experience, the morbidity can decrease progressively by analyzing the leading cause and improving the technical skills.

Neuroendocrine tumor of the pancreas (pNET) is a rare group of neoplasms with widely heterogeneity. Complete surgical resection remains the only potentially curative treatment for pNET. Compared to open surgery, minimal invasive approach treating pNET could decrease bleeding and shorten postoperative hospital stay, while didn′t show difference in operation time, postoperative complication rate and overall mortality. Therapeutic strategy was formulated by synthesizing clinical symptoms, tumor size and tumor stage. Minimal invasive approach can achieve radical curve of oncology and provide refine manipulation condition to improve surgical safety and efficacy, meanwhile realize function preservation. Minimal invasive approach is a safe and efficient method in treating pNET, but further prospective, randomized control trials are required.