Objective To compare the clinical efficacies of totally laparoscopic and laparoscopy-assisted radical total gastrectomies.Methods The retrospective cohort study was conducted.The clinicopathological data of 373 patients with gastric cancer who underwent totally laparoscopic or laparoscopy-assisted radical total gastrectomies from the 7 medical centers in China (82 patients in the Affiliated Hospital of Qinghai University,80 in the Traditional Chinese Medicine Hospital of Guangdong Province,60 in the First Affiliated Hospital of Xiamen University,51 in the Hangzhou First People's Hospital,46 in the First Affiliated Hospital of Xi'an Jiaotong University,30 in the Second Affiliated Hospital of Jilin University and 24 in the Xijing Hospital of the Fouth Military Medical University) between January 2015 and December 2016 were collected.Of 373 patients,the 183 and 190 patients were respectively divided into the totally laparoscopic group (undergoing totally laparoscopic radical total gastrectomy) and laparoscopy-assisted group (undergoing laparoscopy-assisted radical total gastrectomy),including 63 and 19 in the Affiliated Hospital of Qinghai University,36 and 44 in the Traditional Chinese Medicine Hospital of Guangdong Province,25 and 35 in the First Affiliated Hospital of Xiamen University,20 and 31 in the Hangzhou First People's Hospital,10 and 36 in the First Affiliated Hospital of Xi'an Jiaotong University,17 and 13 in the Second Affiliated Hospital of Jilin University,12 and 12 in the Xijing Hospital of the Fouth Military Medical University.Routine five-port method was applied for laparoscopic radical total gastrectomy and D2 lymphadenectomy.Roux-en-Y anastomosis was applied for digestive tract reconstruction,and digestive tract reconstruction was performed under laparoscopy in the totally laparoscopic group and via upper abdominal median incision in the laparoscopy-assisted group.Observation indicators:(1) operation and postoperative situations;(2) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect the postoperative overall survival and tumor recurrence or metastasis up to March 2017.Measurement data with normal distribution were represented as x±s.Comparison between the groups was analyzed by the t test.Measurement data with skewed distribution were represented as M (range).Comparisons of count data were analyzed using the chi-square test and Fisher exact probability.Results (1)Operation and postoperative situations:all the patients in the 2 groups underwent successful operations,without perioperative death.Esophagojejunostomy methods of 183 patients in totally laparoscopic group:conventional circular stapler method were performed in 28 patients,anti-puncture circular staplar method in 6 patients,OrVilTM method in 5 patients,functional end-to-end esophagojejunostomy method in 65 patients and peristalsis side-to-side esophagojejunostomy method in 79 patients.Conventional circular stapler method was applied to 190 patients in the laparoscopy-assisted group.Operation time,time of esophagojejunostomy,length of assisted incision,using time of analgesics and expenses of digestive tract reconstruction were (238± 55)minutes,(29±9)minutes,(5.1 ± 1.1)cm,(2.2±l.0)days,(18 332±2 141)yuan in the totally laparoscopic group and (217±39)minutes,(26±7)minutes,(7.8 ±2.0)cm,(2.7± 0.9)days,(16 237 ± 1 923)yuan in the laparoscopy-assisted group,respectively,with statistically significant differences between the 2 groups (t =4.324,3.455,-16.835,-5.561,9.949,P＜0.05).The cases with postoperative overall complications,anastomosis leakage,anastomosis stricture,anastomosis bleeding and expenses of esophagojejunostomy were respectively 24,9,7,5,(9 668±2 814)yuan in the totally laparoscopic group and 24,8,9,6,(9 331 ±2 067)yuan in the laparoscopy-assisted group,with no statistically significant difference between the 2 groups (x2 =0.036,0.107,0.189,0.059,t=1.322,P＞0.05).All the patients with postoperative complications were cured by symptomatic treatment.(2) Follow-up and survival situations:of 373 patients,336 were followed up for 4-26 months,with a median time of 13 months,including 166 in the totally laparoscopic group and 170 in the laparoscopy-assisted group.During the follow-up,cases with overall survival,tumor recurrence and tunor metastasis were respectively 150,10,16 in the totally laparoscopic group and 154,9,16 in the laparoscopy-assisted group (10 and 9 patients in the totally laparoscopic and laparoscopy-assisted groups with simutaneous tumor recurrence and metastasis),showing no statistically significant difference between the 2 groups (x2 =0.075,0.010,P＞0.05).Conclusions Total laparoscopic and laparoscopyassisted radical total gastrectomies are safe and feasible,with equivalent overall outcomes and effects of esophagojejunostomy.Compared with laparoscopy-assisted radical total gastrectomy,the postoperative pain time of patients in total laparoscopic radical total gastrectomy is less,but there are longer time of esophagojejunostomy and higher expenses of digestive tract reconstruction.

Objective To investigate the clinical efficacy of laparoscopic hepatectomy and summarize its experiences.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 2 048 patients who underwent laparoscopic hepatectomy in the Southwest Hospital of the Third Military Medical University from March 2007 to October 2016 were collected.The resectability of lesions and liver functional reserve were preoperatively evaluated,and then laparoscopic hepatectomy was conducted.Observation indicators:(1)surgical and intraoperative situations;(2) follow-up situations.Follow-up using outpatient examination and telephone interview was performed to detect the patients' postoperative survival up to June 2017.Measurement data with normal distribution were represented as (x)±s.Count data were evaluated by the percentage.The survival rate was calculated by the Kaplan-Meier method.Results (1) Surgical and intraoperative situations:all the 2 048patients received successful laparoscopic hepatectomy,including 1 985 undergoing traditional laparoscopic hepatectomy and 63 undergoing Da Vinci robot-assisted and laparoscopic hepatectomy.Non-anatomical and anatomical hepatectomies were respectively applied to 1 052 and 996 patients.The rate of conversion to open surgery of 2 048 patients was 6.738％ (138/2 048).Operation time,volume of intraoperative blood loss and rate of intraoperative blood transfusion in 2 048 patients were (225±27)minutes,(455± 152)mL and 5.615％ (115/2 048),respectively.The incidence of postoperative complications was 11.816％ (242/2 048),42.149％ (102/242) of postoperative complications included reactive pleural effusion and effusion in the resection margin,and other postoperative complications included peritoneal effusion,pulmonary infection,abdominal infection,bile leakage,bleeding,incision liquefied,thrombus and acute liver injury.The incidence of postoperative severe complications was 0.488％ (10/2 048),including 6 with intraperitoneal bleeding,1 with acute respiratory distress syndrome,1with cardiac failure,1 with hepatic failure and 1 with renal failure.Of 242 patients with postoperative complications,6 with intraperitoneal bleeding received reoperations and were improved,1 died of extensive thrombus of portal vein system induced liver failure,and 235 were improved by conservative treatment.Duration of hospital stay in 2 048 patients was (10.7± 1.0)days.(2) Follow-up situations:912 of 1 070 patients with malignant liver tumors were followed up for 8-120 months,with a median time of 51 months.The 1-,3-and 5-year overall survival rates and 1-,3-and 5-year tumor-free survival rates in 912 patients with malignant liver tumors and follow-up were 94.1％,82.2％,53.6％ and 82.3％,61.3％,32.8％,respectively.Conclusions Laparoscopic hepatectomy is safe and feasible,with definite effects.In the premise of breakthroughs of technical bottlenecks in the bleeding control and exposure of special liver segment,the indications for laparoscopie hepatectomy have been expanded and there is no restricted area.

The.progress in diagnosis and surgical treatment of gastric cancer contributes to the raised diagnosis rate and 5-year survival rate of gastric cancer patients in Japan. According to the clinical data of 273 142 Japanese gastric cancer patients from 1962 to 1991, the proportion of patients with stage I gastric cancer was increased from 22.5% to 58.1%, and the accumulative 5-year survival rate from 37.5% to 68.8%. The improvement of the accumulative 5-year survival rate was remarkable for patients with stage Ⅱ gastric cancer (from 47.7% to 70.3%) and stage Ⅲ gastric cancer (from 26.4% to 45.0%).

Objective To investigate the application value of limited liquid resuscitation combined with continuous renal replacement therapy (CRRT) in treatment of severe acute pancreatitis (SAP) companied with abdominal compartment syndrome (ACS).Methods The retrospective cohort study was adopted.The clinical data of 67 patients with SAP companied with ACS who were admitted to the Fuling Center Hospital of Chongqing from January 2005 to December 2014 were collected.Among 67 patients,33 receiving conventional liquid resuscitation between January 2005 and December 2010 were allocated into the control group and 34 receiving limited liquid resuscitation combined with CRRT between January 2011 and December 2014 were allocated into the observation group.Observation indicators included:(1) required fluid volume and time of negative fluid balance in the 2 groups;(2) changes of pathological and physiological indicators after treatment in the 2 groups;(3)outcomes and prognosis of patients in the 2 groups.Measurement data with normal distribution were represented as (x)±s and comparison between groups was analyzed using t test.Count data were analyzed using the chi-square test.Repeated measurement data were analyzed by repeated measures ANOVA.Results (1) Required fluid volume and time of negative fluid balance in the 2 groups:required fluid volumes at 6,24,48 and 72 hours after resuscitation were (2 449±339) mL,(4 820±757) mL,(9 428± 1 272) mL,(13 127± 1 565) mL in the control group and (2 360± 314) mL,(4 582±530) mL,(8 564± 970) mL,(11 470± 1 253) mL in the observation group,respectively,with a statistically significant difference in required fluid volume between the 2 groups (F=13.035,P＜0.05) and in required fluid volume at 48 and 72 hours between the 2 groups (t=3.132,4.794,P＜0.05).Time of negative fluid balance in the observation group and control group was (4.3± 1.7)days and (6.4 ±1.8)days,respectively,showing a statistically significant difference between the 2 groups (t =4.913,P＜0.05).(2) Changes of pathological and physiological indicators in the 2 groups after treatment:time factors:from 0 h to 168 h postoperatively,APACHE Ⅱ score,C-reaction protein (CRP),D-dimer,IAP,Bla and oxygenation index were changed from 20.9±4.1 to 13.9±2.6,from (167±39)mg/L to (55±17) mg/L,from (1 652±1 544) μg/L to (993±500)μg/L,from (23.4±3.4)cmH2O (1 cmH2O=0.098 kPa) to (21.4±2.9)cmH2O,from (4.6±1.6) mmol/L to (1.4±0.5)mmol/L,from (189±27) mmHg (1 mmHg =0.133 kPa) to (152±23)mmHg in the control group,and chaged from 21.5±5.1 to 11.0±2.8,from (168±36)mg/L to (44±19)mg/L,from (1 634±1 525) μg/L to (578±350) μg/L,from (23.2±2.5)cmH2O to (17.4±2.6)cmH2O,from (4.5±1.6)mmol/L to (0.8±0.3)mmol/L,from (188±26)mmHg to (196±25)mmHg in the observation group,respectively,showing gradual decreasing with time and statistically significant differences between the 2 groups (F =186.415,581.118,34.618,212.416,262.272,207.645,P＜0.05).Treatment factors:there were no significant differences in changing trends of APACHE Ⅱ score,D-dimer and Bla between the 2 groups (F=3.499,2.350,3.516,P＞0.05),and there were significant differences in changing trends of CRP,IAP and oxygenation index between the 2 groups (F=4.009,15.276,14.959,P＜0.05).Interaction effect between time factors and treatment factors:there were obviously interaction effects between time factors and treatment factors in APACHE Ⅱ score,CRP,IAP and oxygenation index (F=4.890,4.912,23.874,28.615,P＜0.05) and no interaction effects between time factors and treatment factors in D-dimer and Bla (F=2.803,1.920,P＞0.05).(3) Outcomes and prognosis of patients in the 2 groups:numbers of patients with surgery,local complications and infection and duration of hospital stay were 11,16,14,(46±17)days in the control group and 4,6,6,(36±14) days in the observation group,respectively,with statistically significant differences between the 2 groups (x2=4.484,7.221,4.910,t =2.433,P＜0.05).Mortality and hospital expenses were 24.2％ (8/33),(33± 18) x 104 yuan in the control group and 8.8％ (3/34),(27± 14)× 104 yuan in the observation group,respectively,with no statistically significant difference between the 2 groups (x2 =2.901,t =1.283,P＞ 0.05).Conclusion Limited liquid resuscitation combined with CRRT can effectively control IAP of patients with SAP companied with ACS and improve oxygenation index,meanwhile,it can also reduce number of patients with surgery,infection and local complications and duration of hospital stay.

Objective To investigate the risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy (PD).Methods The retrospective case-control study was adopted.The clinicopathological data of 196 patients with PD who were admitted to First Affiliated Hospital of Dalian Medical University from September 2014 to July 2016 were collected.All the patients underwent PD.Observation indicators:(1) intra-and postoperative situations;(2) follow-up;(3) analysis of risk factors of pancreatic fistula after PD.All patients were followed up by outpatient examination and telephone interview to detect pancreatic fistula and peritoneal fluid collection up to March 2017.Measurement data with normal distribution were represented as (x)±s and comparison between groups was analyzed by t test.Measurement data with skewed distribution were represented as median (range).Count data and univariate analysis were done using the chi-square test.Logistic regression model was used for multivariate analysis.Results (1) Intra-and post-operative situations:all the 196 patients underwent surgeries successfully.The operation time,volume of intraoperative blood loss,number of intraoperative blood transfusion and non intraoperative blood transfusion were (439± 136) minutes,(686±280) mL,45 and 151 cases,respectively.Time to initial anal exsufflation,time of initial defecation and time for first diet after operation were (4.1 ±2.1) days,(5.1± 2.9) days and (3.1 ± 2.0) days.Of 76 patients,the content of diastase in the i ntraperitoneal drainage was 614 U/L (31-30 215 U/L) at postoperative day 1 and level of serum procalciton in was (0.7±0.4) ng/mL at postoperative day 3.Time for drainage tube removal of 196 patients was (14.6±7.1)days.Fifty four of 196 patients with postoperative complications were improved by symptomatic treatment,including 15 with intestinal obstruction,12 with delayed gastric emptying,11 with abdominal infection,9 with incision infection,7 with bleeding.Duration of postoperative hospital stay was (17.1 ±4.2)days.Results of pathological diagnosis of 196 patients showed 121 cases of pancreatic cancer,50 of intraductal papillary mucinous tumors of the pancreas,7ampullary carcinoma,15 of carcinoma of the lower end of the bile duct,and 3 of duodenum cancer.Pancreatic findings:pancreatic texture:95 cases were with soft pancreas and 101 with hard pancreas.Diameter of main pancreatic duct duct:101 cases had diameter of pancreatic duct duct ≥3 mm and 95 cases ＜3 mm.(2)Followup:all the 196 patients were followed up for 4-30 months,with a median follow-up time of 18 months.During follow-up time,the grade B/or C pancreatic fistula occurred in 37 cases.Of 16 patients with pancreatic fistularalated ascites,10 had readmission and were improved by symptomatic treatment.(3) Analysis of risk factors of pancreatic fistula after PD:the results of univariate analysis showed that the content of diastase in the intraperitoneal drainage at postoperative day 1,level of serum procalcitonin at postoperative day 3 and pancreatic texture were related factors affecting the pancreatic fistula after PD (x2 =6.569,5.902,13.517,P＜0.05).The results of multivariate analysis showed that the content of diastase in the intraperitoneal drainage at postoperative day 1 ≥600 U/L was an independent risk factor affecting the pancreatic fistula after PD (OR =9.135,95％confidence interval:2.247-37.130,P＜0.05).Conclusion The content of diastase in the intraperitoneal drainage at postoperative day 1 ≥ 600 U/L is an independent risk factor affecting the pancreatic fistula after PD.

Objective To investigate the clinical efficacy of modified FOLFIRINOX as neoadjuvant chemotherapy for borderline resectable pancreatic cancer.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 28 patients diagnosed as borderline resectable pancreatic cancer who were admitted to the Tianjin Medical University Cancer Institute and Hospital between April 2013 and October 2015 were collected.Twenty-eight patients were treated with modified FOLFIRINOX (irinotecan 135 mg/m2,oxaliplatin 64 mg/m2,leucovorin 400 mg/m2,5-FU 2 400 mg/m2,repeat the regimen every 2 weeks) as neoadjuvant chemotherapy.After the completion of neoadjuvant chemotherapy,patients were evaluated operation feasibility and developed surgical planning in 3 weeks.Observation indicators:(1) Efficacy of neoadjuvant chemotherapy;(2) adverse events of neoadjuvant chemotherapy;(3) surgical and postoperative situations;(4)follow-up situations.Follow-up using outpatient examination,telephone interview and we-chat was performed to detect survival of patients up to January 2017.Measurement data with skewed distribution were described as median (range).The survival curve was drawn by Kaplan-Meier method and the survival analysis was done by Log-rank test.Results (1) Efficacy of neoadjuvant chemotherapy:28 patients received chemotherapy with a median cycle of 6 cycles (range,3-12 cycles).Chemotherapy reaction of 28 patients:14 had partial remission,10 had stable disease and 4 had progressive disease.(2) Adverse events of neoadjuvant chemotherapy:there were 22 adverse events of 28 patients during chemotherapy,including 15 with grade1-2 and 7 with grade 3-4.(3)Surgical and postoperative situations:of 28 patients,18 received radical resection for pancreatic cancer including 11 receiving pancreaticoduodenectomy,7 receiving distal pancreatectomy with splenectomy.Surgeries included 6 with portal vein and superior mesenteric vein resection and reconstruction,1 with coeliac trunk resection.Ten patients received R0 resection and 8 received R1 resection.Of 18 patients,8 with postoperative complications were improved by conservative treatment,including 2 with pancreatic fistula,1 with biliary fistula,3 with delayed gastric empty,1 with anastomotic hemorrhage,1 with lympha fistula.No patient received re-operation or died within 30 days postoperatively.Pathological TNM staging:2 patients were detected in stage Ⅰ-Ⅱ,14 in stage Ⅲ and 2 in stage Ⅳ.All the 18 patients received chemotherapy after operation.Ten patients without operation continued chemotherapy.(4) Following up:28 patients were followed up for 5-21 months with a median time of 13 months.Of the 15 died patients,5 received operation and 10 received no operation.The median progressionfree survival time and median overall survival time were 14 months and 19 months in the 18 operative patients,7 months and 11 months in the 10 non-operative patients,respectively,with statistically significant differences (x2=7.335,9.950,P＜0.05).Conclusions Modified FOLFIRINOX as neoadjuvant chemotherapy for borderline resectable pancreatic cancer is safe and effective,and patients can tolerate mild adverse reactions.Operable patients undergo surgeries after chemotherapy have relatively good outcome.

Objective To investigate the clinical features and treatment of solid pseudopapillary neoplasm (SPN) of the pancreas.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 69 patients with SPN of the pancreas who were admitted to the Qilu Hospital of Shandong University from January 2012 to July 2017 were collected.Serum tumor markers detection,enhanced computed tomography (CT) and magnetic resonance imaging (MRI) of abdomen were carried out preoperatively for all the patients,and a part of the patients received endoscopic ultrasonography (EUS).Surgery plans were formulated after completion of examinations.Observation indicators:(1) clinical features;(2) treatment situation;(3) results of pathological examination;(4)follow-up.All the patients were followed up via outpatient examination and telephone interview to detect the survival and tumor recurrence and metastasis till July 2017.Measurement data with normal distribution were presented by (x)±s and were compared by Student's t test.Count data were compared by chi-square test.Results (1) Clinical features:① epidemiologic features:the ratio of male to female was 1∶5.9;patients were aged between 9 and 65 years,including 40 under 30 years and 29 above or equal to 30 years.The onset age was (34± 15)years for male patients and (28 ± 11)years for female patients,respectively,with no statistically significant difference (t=1.364,P＞0.05).Of 69 patients,SPN was located at pancreatic uncinate process in 25 patients,at neck of pancreas in 12 patients,body and tail of pancreas in 32 patients.② Medical history:history of acute or chronic pancreatitis and abdominal trauma were denied by all the 69 patients.③ Clinical manifestation:26 patients had no obvious symptoms and were detected by physical examination;31 patients had discomfort in upper abdomen,nausea and vomiting;other patients were admitted to the hospital because of upper abdominal mass (10 patients),jaundice (1 patient) or nausea,constipation (1 patient).④ Laboratory examination:the levels of preoperative carcinoembryonic antigen (CEA) and CA19-9 were normal.⑤ Imaging examination:plane scan of the CT examination showed round or round-like low-density shadows in the 69 patients,including 51 of cystic solid lesion,13 of solid lesion and 5 of cystic lesion.Complete capsules were observed in 64 patients,blurred boundary between pancreas and adjacent viscera in 5 patients,calcified foci in the pancreatic parenchyma and capsules in 14 patients.Ten patients received MRI examination,and the T1-weighted images showed equal or slightly lower signal,T2-weighted images showed slightly higher signal in the plane scan,and T1-weighted and T2-weighted images of the tumor capsule showed continuous or non-continuous ring-like signal.The results of enhanced scan showed slightly heterogeneous enhancement of the capsule and the parenchyma of the pancreas in the arterial phase,and progressive enhancement in the venous and delayed phase,while the enhancement degree was lower than that of the normal pancreas parenchyma.The parenchyma was cloud-,papillaor mural nodule-like enhanced.Obvious enhancement was observed in capsule while not in the cystic components.The boundaries of the tumors in 5 patients were clear under EUS.Hypo-,iso-and hyperechoic regions were found in the masses,and the masses were confirmed as cyst-solidary type.Obvious calcified foci were found in 1 patient.(2) Treatment outcome:twenty-seven patients received laparoscopic surgery,including tumor expiration in 13 patients,distal pancreatectomy with preservation of spleen in 8 patients,distal pancreatectomy combined with splenectomy in 2 patients,middle pancreatectomy in 2 patients,pancreaticoduodenectomy with preservation of pylorus in 1 patient,pancreatic head resection with preservation of duodenum under the assistance of laparoscopy in 1 patient.Forty-two patients received open surgery,including tumor expiration in 12 patients,distal pancreateetomy with preservation of spleen in 10 patients,distal pancreatectomy combined with spleneetomy in 6 patients,middle pancreatectomy in 5 patients,pancreaticoduodenectomy in 7 patients (with preservation of pylorus in 2 patients) and pancreatic head resection combined with preservation of duodenum in 1 patient.One patient with SPN + hepatic metastasis received distal pancreatectomy+ metastatic foci resection in the lesser omental bursa,and then followed by radiofrequency ablation in the hepatic metastatic foci.Postoperative complications:21 of 69patients had postoperative complications,including 17 intestinal fistulas,2 abdominal bleedings,1 incomplete obstruction,1 pleural effusion + atelectasis,and all of them were cured by symptomatic treatment.(3)Pathological examination:the resection margins of 69 patients were negative.The mean diameter of the tumor was (7±4) cm (21 patients with tumor diameter ＜ 5 cm,and 48 with tumor diameter ≥5 cm).The tumor diameters of 4 in 10 male patients were above or equal to 5 cm,and the number was 44 in 59 female patients,with statistically significant difference (x2 =4.828,P＜0.05).The tumor diameters of 32 in 40 patients who aged under 30 years were above or equal to 5 cm,and the number was 16 in 29 patients who were aged above or equal to 30 years,with statistically significant difference (x2=4.895,P＜0.05).Solid,pseudo-papillary and cystic regions in the SPN tissues were seen under the light microscope.Tumor cells were surrounded the blood vessels and were arranged in the nest or sheet shape in the solid region;blood vessels were surrounded by one or multiple layers of tumor cells in the axis or pseudopapillary shape in the pseudopapillary region;large amount of mucus and clusters of blood cells were seen in the cystic regions.The result of immunohistochemistry showed that the positive rates of α1-antitrypsin,vimentin,β-catenin,progesterone receptor,CD10,synaptophysin and chromogranin A were 100.0％ (39/39),96.6％ (28/29),95.7％ (45/47),94.4％ (51/54),92.5％ (49/53),72.9％ (35/48) and 5.6％ (3/54),respectively.(4) Follow-up:63 of 69 patients were followed up for 1-68 months,with median time of 29 months.No SPN recurrence or metastasis was detected.One patient died of lung cancer at postoperative month 35 and other patients survived well.Conclusions SPN of pancreas is mostly detected in young female patients,and it could be solid or cystic.Abdominal enhanced CT or MRI examination could clarify the diagnosis.EUS-fine needle aspiration examination could provide pathological evidence for definitive diagnosis.Typical cellular morphology and pseudopapillary regions may provide hints for the diagnosis of SPN,and the diagnosis could be clarified when combined with the detection of vimentin,α 1-antitrypsin or other indexes.Complete resection of SPN and ensure negative resection margin are fundamental principles of treatment.

Objective To investigate the clinical features and surgical indications of subtypes of intraductal papillary mucinous neoplasm (IPMN) of the pancreas,and analyze its malignant risk factors.Methods The retrospective case-control study was conducted.The clinicopathological data of 77 patients with IPMN of the pancreas who were admitted to the First Hospital of Peking University from January 2008 to December 2016 were collected.The subtypes of IPMN of the pancreas detected by preoperative imaging examination included main-duct type (MD-IPMN) in 46 patients,branch-duct type (BD-IPMN) in 12 patients,mixed type (MT-IPMN) in 19 patients.The surgical indications were consulted from the Guideline for the diagnosis and treatment of pancreatic cystic lesions composed by the Pancreatic Surgery Group of Surgery Branch of China Medical Association.Surgical procedure was selected according to the location and size of the IPMN.Four to 6 cycles of chemotherapy with S-1 and/or Gemcitabine were conducted for patients with malignant IPMN according to the tolerance and baseline characteristics.Observation indicators included:(1) comparison of the clinical features MD-IPMN,MT-IPMN and BD-IPMN;(2) surgical and postoperative conditions;(3) results of postoperative pathological examination and malignant risk factors analysis;(4) accuracy evaluation of Sendai and Fukuoka guidelines for the diagnosis of malignant IPMN of the pancreas;(5) follow-up results and survival.Patients were followed up by outpatient examination and telephone interview till December 2016.The postoperative adjuvant therapy,tumor recurrence and metastasis of malignant IPMN patients and postoperative survival condition of all the patients were collected.Measurement data with normal distribution were expressed as (x)±s or average (range),and pairwise comparison was analyzed by t test.Measurement data with skewed distribution were expressed by median (range).Comparison between count data and univariate analysis were done by chi-square test.Multiple factors analysis was done by Logistic regTession model.The survival curve was drawn and the survival rate were calculated by Kaplan-Meier method.The comparison of survival was done by Log-rank test.Results (1) Comparison of clinical features between MD-IPMN,MT-IPMN and BD-IPMN:The numbers of patients with symptoms,jaundice,those complicated with diabetes and elevated CA19-9 were 55,20,43 and 28 in MD-IPMN and MT-IPMN,and 6,0,3 and 1 in BD-IPMN,with statistically significant difference (x2=5.421,3.516,5.525,3.834,P＜0.05).(2) Surgical and postoperative conditions:the operations for all the 77 patients were successfully done,including pancreaticoduodenectomy with or without preservation of pylorus on 45 patients,resection of head of pancreas with duodenum preservation on 3 patients,distal pancreatectomy on 23 patients,distal pancreatectomy combined with partial resection of spleen and stomach on 2 patients (with greater curvature of stomach involvement),segmental pancreatectomy on 2 patients,total pancreatectomy on 2 patients.A total of 26 surgery-related complications were detected,including pancreatic fistulas (13),delayed gastric emptying (9),wound infection (2),abdominal hemorrhage (2),and all the complications were improved by conservative treatment.There was no perioperative mortality.The mean duration of hospital stay of the 77 patients was 16 days (range,6-68 days).(3) Results of postoperative pathological examination and malignant risk factor analysis:① results of postoperative pathological examination:no residual tumor was detected at the resection margin in all the 77 patients,including 47 with benign IPMN (29 with adenoma and 18 with mid-severe atypical hyperplasia and without lymph node involvement) and 30 with malignant IPMN (all of them were invasive malignancy,including 17 patients with negative lymph node metastasis and 13 with positive lymph node metastasis).② Malignant risk factor analysis of IPMN:multivariate analysis showed that age,jaundice,elevated carcinoembryonic antigen (CEA),elevated CA19-9,tumor diameter,tumor subtypes were associated with malignancy (x2 =6.531,14.755,10.243,12.062,6.416,6.143,P ＜ 0.05).Multivariate analysis showed that jaundice,elevated CEA,elevated CA19-9,tumor diameter ≥3.0 cm,MD-IPMN were independent risk factors influencing the malignancy of IPMN (OR =9.656,42.853,23.243,34.387,69.883,95％ confidence interval:1.392-66.968,2.088-879.674,2.991-180.628,3.313-356.878,1.247-3 915.467,P＜0.05).(4) Accuracy evaluation of the Sendai and Fukuoka guidelines in diagnosis of malignant IPMN.The sensitivity,specificity,positive and negative predictive values were 100.0％(30/30),14.9％ (7/47),42.9％ (30/70) and 100.0％ (7/7) for the Sendai guideline and 86.7％ (26/30),48.9％ (23/47),52.0％ (26/50),85.2％ (23/27) for the Fukuoka guideline in diagnosis of malignant IPMN,with no significant difference in the sensitivity between the 2 guidelines (x2=2.250,P＞0.05),while significant difference in the specificity between the 2 guidelines were detected (x2 =12.500,P＜0.05).(5) Follow-up and survival:Seventy of 77 patients were followed up,including 42 with benign IPMN and 28 with malignant IPMN.The median survival time was 35.0 months (range,6.0-94.0 months).All the malignant IPMN patients received adjuvant therapy.The 1-,3-,5-year overall survival rates of 47 patient with benign IPMN were 100.0％,96.2％and 96.2％,respectively,and 1 patient died of cardiac infarction.The 1-,3-,5-year overall survival rates of 30 patients with malignant IPMN were 96.6％,81.8％,38.6％,respectively,and 11 patients died of tumor recurrence or metastasis with median time of tumor recurrence or metastasis of 20.5 months (6.0-61.6 months).The 1-,3-,5-year overall survival rates of 17 patients with negative lymph node metastasis were 100.0％,100.0％ and 60.0％,respectively,and the 1-,3-,5-year overall survival rates of 13 patients with positive lymph node metastasis were 91.7％,57.1％ and 0,respectively.There was statistically significant difference between patients with benign and malignant IPMN (x2 =12.530,P＜0.05).There was statistically significant difference between patients with negative lymph node metastasis and those with positive lymph node metastasis (x2 =16.977,P＜ 0.05).Conclusions Patients with MD-IPMN or MT-IPMN are more vulnerable to be complicated with diabetes,jaundice,elevated CA19-9 and high malignancy,and thus surgery is recommended.Jaundice,elevated CEA and CA19-9,tumor diameter≥3.0 cm,MD-IPMN are the independent risk factors influencing the malignancy of IPMN.

Locally advanced pancreatic cancer (LAPC) involves with adjacent vascular structures,which is divided into the borderline resectable pancreatic cancer (BRPC) and unresectable pancreatic cancer.BRPC is usually treated with vascular restruction.Neoadjuvant therapy plays an important role in achieving an R0 resection in BRPC.Generally,the goal of treatment for unresectable pancreatic cancer is to control tumor progress and improve patients' quality of life.The latest cheering clinical trials have shown that some LAPC may be downstaged to resectable tumors after preoperative chemotherapy and chemoradiotherapy.In this article,the rationale for and results following treatment with neoadjuvant chemotherapy,chemoradiation and possibly subsequent surgical resection of the primary tumor are described in detail and existing data are reviewed.

With the development of abdominal imaging examination,detection rate of pancreatic cystic neoplasms is increasing in recent years.Misdiagnosis and unreasonable treatment sometimes are unavoidable since the variable subtype,pathology and natural history.Multidisciplinary team (MDT)including surgeons,radiologists,gastro-enterologists and pathologists is very helpful to make an exact diagnosis and appropriate treatment for pancreatic cystic neoplasms.However,because of the complexities of pancreatic cystic neoplasms,challenges and difficulties of MDT always exist.In this article,authors summarized the newest advancement of pancreatic cystic neoplasms and highlighted the experiences in the management of pancreatic cystic neoplasms from MDT,aiming to seek the optimal strategy.