Pancreatic cancer is one of the most common and malignant tumor in the field of digestive system.Surgery still is potential method to cure pancreatic cancer.Laparoscopic surgery with the advantage of minimal invasion has been applied in the treatment of benign and low malignant tumors,but it is in great controversy whether laparoscopic surgery could be used in treatment of pancreatic cancer.This study reviews the literatures of laparoscopic surgery for pancreatic cancer and the clinical outcomes,and explores its current development and prospects.

Objective To explore the effects of injection of wnt3a gene-modified bone marrow mesenchymal stem cells (MSCs) on acute graft-versus-host disease (aGVHD) in a murine allogeneic bone marrow transplantation (allo-BMT) model.Methods C57BL/6 mice were used as the donors and Balb/c mice as the recipients in the murine allo-BMT model.The recipient mice were divided into four groups by random number table method: transplantation control group (group A) (infusion of 5 × 106bone marrow cells via the tail vein of recipient mice); aGVHD group (group B) (infusion of 5 × 106bone marrow cells and 5 × 106 splenocytes via the tail vein of recipient mice); aGVHD + empty vector group (group C) (infusion of 5 × 106 bone marrow cells,5 × 106 splenocytes and 1 × 106 pAd-GFP-transfected MSCs via the tail vein of recipient mice) ; experimental group (group D) (infusion of 5 ×106 bone marrow cells,5 × 106 splenocytes and 1 × 106 wnt3a gene-modified MSCs).The general performance and survival were monitored,the occurrence of aGVHD was observed,the changes of donor T lymphocyte quantity present in the spleen,and interleukin-2 (IL-2) and interferon-γ (IFN γ)levels of the recipient mice were detected in each group after transplantation.Results The survival time of recipient mice in group A was all more than 60 d,and that in groups B,C and D was (19.1 ±6.19),(32.6 ± 19.6) and (47.2 ± 15.6) d,rcspcctivcly.The survival time in group D was significantly longer than in groups B and C (P＜0.05).After the transplant,the aGVHD score points in groups B,CandDwere (8.0±0.41),(6.7±0.29) and (4.0± 1.0),respcctively.The aGVHD score points in group D were significantly less than in groups B and C (P＜0.05),and the pathological grade in group D was significantly reduced.The number and proliferation rate of T lymphocytes were reduced significantly in group D as compared with groups B and C at 3rd and 5th day after transplantation (P ＜ 0.05).The levels of IL-2 and IFN-γ in peripheral blood were decreased significantly in group D as compared with those in groups B and C at 7th,14th,21st and 28th day after transplantation (P＜0.05).The chimeric rate of the murine H-2Kb cells in the bone marrow cells of long-term survival mice was all in the range of 95％ to 100％ 60 d after transplantation.Conclusion The injection of wnt3a gene-modified MSCs can more effectively alleviate aGVHD in murineallo-BMT model,which may be correlated with the Wnt3a overexpression which activating the Wnt/β-catenin signaling pathway of MSCs,thereby inhibiting the early activation and amplification of donor T lymphocytes and the IL-2 and IFN-γ expression.

Objective To investigate clinical efficacy of Easy First strategy in laparoscopic pancreaticoduodenectomy (PD) for borderline resectable pancreatic cancer.Methods The clinical data of 9 patients with borderline resectable pancreatic cancer who were admitted to the Sir Run Run Shaw Hospital of Zhejiang University (8 patients) and Zhejiang Provincial People's Hospital (1 patient) from June 2013 to March 2015 were retrospectively analyzed.Nine patients underwent laparoscopic pancreaticoduodenectomy based on the Easy First strategy (to sequentially dissect and amputate jejunum,stomach,hepatoduodenal ligament,common bile duct,main portal vein,head of pancreas,second segment and third segment of the duodenum,uncinate process and neck of pancreas).The operation time,volume of intraoperative blood loss,postoperative pathological examination,complications and duration of hospital stay were recorded.Patients were followed up once every 3 months by outpatient examination and telephone interview up to June 2015.Results Of 9 patients,4 received totally laparoscopic PD (2 received partial resection and repair of portal venous wall),1 received laparoscopic assisted resection and digestive tract reconstruction,and 4 received laparoscopic transection of jejunum,bile tract and stomach and conversion to open surgery for resection and digestive tract reconstruction (1 with severe adhesion between tumor and portal vein,3 with bleeding due to dissection of neck and unciform process of pancreas).The operation time and volume of intraoperative blood loss in all patients and in 4 patients with totally laparoscopic PD were (404 ± 49) minutes and (456 ± 348) mL,(395 ± 61) minutes and (188 ± 25) mL,respectively.Of 9 patients,5 with postoperative complications were cured without perioperative death,including 2 with Grade B pancreatic fistula,1 with biliary leakage,1 receiving reoperation due to gastric stump bleeding at postoperative day 7 and 1 with abdominal infection.The extubation time of right drainage tube and left drainage tube was (9 ± 5) days and (11 ± 4) days,respectively.The duration of hospital stay was (24 ± 10)days.All patients were diagnosed as with pancreatic cancer by pathological examinations with the tumor diameter of (3.2 ± 0.8) cm.The number of harvested lymph nodes in all patients and in 4 patients with totally laparoscopic PD were 16.8 (range,6.0-25.0) and 19.8 (range,15.0-25.0).All the patients were followed up for mean time of 12 months (range,4-24 months),including 1 death at postoperative month 3,1 with tumor survival of 20 months and others with tumor-free survival.The postoperative survival time of 4 patients was more than 18 months at the end of follow-up.Conclusion Easy First strategy in laparoscopic PD is safe,feasible and practical for borderline resectable pancreatic cancer.

OBJECTIVETo evaluate the feasibility and safety of laparoscopic pancreaticoduodenectomy(LPD).

METHODSData of 66 patients from Sir Run Run Shaw Hospital undergoing LPD from September 2012 to September 2014 were reviewed. There were 44 male and 22 female with the mean age of (58.7±10.3) years and mean body mass index of (23.5±3.9)kg/m(2). Forty-five patients presented the symptoms and four of all had the history of abdominal surgery, including 2 cases of laparoscopic pancreatic surgery.

RESULTSOf 66 patients underwent laparoscopic procedure, 1 patient underwent LPD combined with right hepatic resection, 1 patient underwent laparoscopic distal gastrectomy with LPD, and 1 patient underwent LPD after laparoscopic distal pancreatectomy. The mean operative time was (367±49) minutes. The mean blood loss was(193±126)ml. The rate of overall postoperative complications was 36.4%(24/66), with 4.5%(3/66) of B or C pancreatic fistula and 7.6% (5/66) of bleeding. The mean postoperative hospital stay was (18.9±12.1) days. Mean tumor size was (3.8±2.3) cm, and the mean number of lymph nodes harvested was (20.3±10.9). Forty-severn patients were diagnosed as pancreatic adenocarcinoma(n=18), cholangiocarcinoma(n=7), ampullary adenocarcinoma(n=21), and gastric cancer(n=1), respectively.

CONCLUSIONLPD is feasible and safe under the skilled hand.

Adenocarcinoma ; surgery ; Aged ; Anastomosis, Surgical ; Female ; Humans ; Laparoscopy ; Length of Stay ; Male ; Middle Aged ; Operative Time ; Pancreatectomy ; Pancreatic Fistula ; pathology ; Pancreatic Neoplasms ; surgery ; Pancreaticoduodenectomy ; Postoperative Complications

This review focused on the progress in laparoscopic pancreaticoduodenectomy(LPD) in the past six years.With the appropriate approaches under laparoscopy, including the resection and reconstruction, LPD has been proved to be safe and feasible. In some centers, LPD has been routine with rapid growth of numbers, it not only benefit the patients with fast recovery, but also benefit the trainees with similar sights as the primary surgeon and good videos of the procedures. However, LPD is still controversial as the more complications in some centers and inconclusive oncologic outcomes. Thus, in the further, a long-time outcome monitoring of LPD is essential. A registry of a prospectively maintained database may be a need for LPD to evaluate its outcomes by multicenter randomized control trials, and real world research may be of value. Structured LPD training programs are valuable for the new surgeons.

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.

Objective To investigate the current situation of mobile phone addiction among nursing undergraduates in Wuhan,and to analyze influencing factors.Methods 240 nursing undergraduates from three universities in Wuhan were selected from January to April 2015 by convenience sampling method,and were evaluated about their situation on mobile phone addiction by questionnaire of mobile phone addiction tendency scale.Single factor analysis and Logistic multiple regression analysis were used for the influencing factors.Results 240 questionnaires were handed out with 232 retrieved and with effective rate 96.67％.Among the 232 nursing undergraduates,mobile phone addiction rate was 30.60％,with scores in the mobile phone addiction tendency scale (48.33 ± 14.23) points.It was revealed in the single factor analysis that differences appeared whether they were in single-parent family,the only child in the family,from a single-parent family or in a love relation (x2=7.45,4.63,12.59;P＜0.05);it was revealed in the Logistic regression analysis that influencing factors included whether they were in single-parent family,the only child or in a love relation.Conclusions Mobile phone addiction rate is relatively high among nursing undergraduates,with those who are in single-parent family,the only child or in a love relation more likely to be addicted.Guidance and education should be strengthened to nursing students,especially to those who are in single-parent family,the only child and who are in a love relation.

Objective: To summary the experience of 233 cases of laparoscopic pancreaticoduodenectomy (LPD) performed by a single surgical team. Methods: Data of patients undergoing LPD from September 2012 to October 2016 were reviewed. There were 145 males and 88 females with the mean age of(60.3±13.0)years old, ranging from 19 to 92 years old, and the mean body mass index of (22.8±3.5)kg/m^2, ranging from 16.3 to 36.8 kg/m². There were 195 patients with clinical manifestation and 54 patients who had the history of abdominal surgery. Results: LPD were performed on 233 patients by same surgical team consecutively. The mean operative time was(368.0±57.4)minutes. Mean blood loss was(203.8±138.6)ml. The postoperative morbidity rate was 33.5%, with 6.9% of grade B or C pancreatic fistula and 9.9% of bleeding. The reoperation rate was 5.6%. The mortality during 30 days after operation was 0.9%. Mean postoperative hospital stay was (18.1±11.2)days. Mean tumor size was (3.9±2.4)cm, and the mean number of lymph nodes harvested was 21.3±11.9.One hundred and sixty-three patients were diagnosed as malignant tumor, including pancreatic adenocarcinoma(n=84), cholangiocarcinoma(n=17), ampullary adenocarcinoma(n=55), duodenal adenocarcinoma(n=5), gastric cancer(n=1)and duel cancer (n=1) located in distal stomach and duodenum. Conclusion The key point to make laparoscopic pancreaticduodenectomy a routine safe procedure is to operate the procedure under skilled hands in selected patients via suitable surgical approaches.

Objective: To evaluate the safety and feasibility of laparoscopic radical antegrade modular pancreatosplenectomy(Lap-RAMPS) for left-sided pancreatic adenocarcinoma. Methods: Clinical data of total 12 patients underwent Lap-RAMPS for left-sided pancreatic adenocarcinoma at Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People′s Hospital from March 2016 to August 2017 were reviewed retrospectively.There were 7 male patients and 5 female patients, with median age of 60.5 years old(47-68 years old). Abdominal enhanced CT, pancreatic MRI, PET-CT were performed on all patients to evaluate the lesion and exclude metastasis.Follow-up were done with out-patient clinic or telephone consultancy until October 2017. Results: All patients underwent pure Lap-RAMPS.The medium operative time was 250 minutes(180-445 minutes), and the blood loss was 150 ml(50-500 ml). The medium first flatus time and diet resumption time were 3.0 days(1-5 days) and 3.5 days(1-7 days) respectively.The medium postoperative hospital stay was 9 days(4-18 days). Morbidity occurred in 8 patients with gastric empty delay(n=1), bleeding(n=1), fluid collection(n=3). There was no mortality.The medium overall number of retrived lymph nodes was 15.6 and the positive rate was 41.7%. The R0 rate was 100%.The medium follow-up was 10 months.One patient was diagnosed as liver metastasis after 8 months and accepted chemotherapy.One patient died after 14 months for tumor recurrence and metastasis.Others survived without tumor recurrence or metasitasis. Conclusion Lap-RAMPS is safe and feasible with accepted oncological outcomes for selected left side pancreatic adenocarcinoma under skilled hands.

Objective:To evaluate the effect of multidimensional model of laparoscopic suture training in spread of laparoscopic pancreatic surgery.Methods:The surgeons who took advanced training in Department of Gastroenterology and Pancreatic Surgery in Zhejiang Provincial People’s Hospital from September 2018 to March 2020 were enrolled. Theoretical presentation, simulation training and assessment, clinical practices were included in the multidimensional training model. The " mattress suture" module (2 mattress sutures) in the LAP Mentor laparoscopic advanced simulator was used as the initial assessment and post-training assessment. The average needle loading time, time to form a knot, total time, accuracy rate of precise needle passage through the entrance and exit dots, and total aggressive tissue handing provided in the LAP Mentor were analyzed pre- and post-training. The trained surgeons were followed up for their clinical work in own hospitals.Results:A total of 13 surgeons were trained, including 4 deputy chief physicians, 7 attending physicians over 3 years, and 2 attending physicians under 3 years. The trainees had only primary laparoscopic surgery experience and no laparoscopic pancreatic surgery experience. After training in the above scheme, the average needle loading time was shortened from (93.6±31.6) s to (45.7±13.6) s, and the time to form a knot was reduced from (138.9±46.2) s to (62.1±22.9) s, and total time to accomplish the suture shortened from (15.9±3.8) min to (6.7±3.5) min. The accuracy rate of precise needle passage through the entrance and exit dots increased from (63.7±10.3)% to (89.6±9.8)%. The total aggressive tissue handing decreased from (18.2±12.5) to (6.7±4.9). All those data showed statistical differences ( P<0.05). During follow-up, all traineescan operate the laparoscopic pancreatic surgery proficiently. One trainee completed his first laparoscopic pancreaticoduodenctomy as the primary surgeon, and one trainee complete the splenic vein branch suture to stop hemostasis during laparoscopic pancreatectomy with spleen-preserving spleen, and 3 trainees completed laparoscopic pancreaticoduodenctomy as the first assistant surgeons with good outcomes. Conclusion:Multidimensional model of laparoscopic suture training can improve the trainee's suture skill and help perform complex laparoscopic pancreatic surgery with self-confidence.